Professor Jennifer Hudson Welcome, my name’s  Jenny Hudson. I am a Professor at the Black Dog   Institute at the University of New South Wales  in Sydney, Australia. Thanks so much for taking   the time to watch this session on how we can use  exposure more effectively for children and young   people with anxiety. Science tells us that we’ll  learn better when we attempt to implement skills,   so I encourage you to practice the strategies  that we talk about today. They might seem easy,   but what we know from research is that it’s really  important that you use your own experience to   practice and to learn how to use these strategies.  And you’ll know from your own experience of   anxiety that facing fears is really hard, and it  causes distress and it’s really hard to make kids   do things that make them scared or worried,  so getting some practice is really important. But welcome. What we’re going to be covering  today is three key things. I’m going to cover,   first, the research evidence on exposure use and  then, talk about some of the common barriers that   people have in using exposure and the common  myths and misconceptions that really prevent   people from using exposure in their therapy  with children and young people. And then,   I’m going to talk really exposures,  step-by-step, and how to deliver a good   exposure, how to use it effectively, and more  effectively than perhaps you have in the past. Alright, so research evidence to start with.  We know that cognitive behavioural treatment   is recommended as the first line of care for  children and young people with anxiety disorders.   Around the world there are a number of different  guidelines, and they all recommend cognitive   behaviour therapy as, really, the first line of  care. There’s been a number of other techniques or   approaches that have been tested, but the research  consistently shows that CBT is the most effective   and the one that has the  most evidence to support it.   The research that’s really led to these  recommendations typically evaluates a   whole treatment package, kind of, delivered in the  same way to all children, and almost all of these   treatments really include two components. There’s  the anxiety management strategies and exposure. So, the anxiety management strategies, kind of,  vary from treatment package to treatment package.   Some might include some psychoeducation,  understanding anxiety, what it’s like,   understanding the, kind of, normal process,  the natural processes of anxiety and fear.   Then there might be cognitive restructuring that’s  added, so helping children to think differently.   We know that children with anxiety tend to expect  the worst in situations. They’re more likely to   look for bad things to happen, and more  likely to predict bad things to happen   in a situation. So, cognitive restructuring  is a technique that is used to help children   think differently, look at  situations in a different way.   Sometimes anxiety management strategies  might include relaxation, helping children   to be calmer or, kind of, lower their arousal in  situations. Some treatment packages might include   problem-solving, kind of, a range of different  anxiety management techniques. So, I’m, kind of,   lumping all together really as anxiety management  techniques, but they vary from package to package. But most treatment packages also include the  second component, which is exposure, and that’s   what we’re going to be talking about today, of  – which is really gradually – can be gradually,   most likely it’s gradually, facing situations  that a child or a young person is scared of.   Using these packages, what we know is that about  a half to two thirds of children and young people   respond favourably. I’m using the terms “children  and young people,” I’m really talking about   school-age children from first year of school  through to high school, end of high school,   and those words will differ depending on  what country you’re in, but in terms of the   application of the strategies today, it’s really  focusing on those children who are of school age.   But we know that using these packages with the  anxiety management techniques and exposure,   about half to two thirds of children will respond  favourably to CBT, so that’s pretty good outcomes. What we also know – this is a systematic review  that was conducted by Stephen Whiteside in 2020   showing that the more treatment focus there is  on in-session exposure, so, kind of, facing your   fears with a Therapist and child together in a  session, the better outcomes for children and   young people. So, that’s pretty good information  about the importance of including exposure,   and also, when comparing effect sizes across   all the different studies that have  looked at these treatment packages,   treatments that included exposure were stronger  when relaxation strategies were not included. That’s really interesting information, ‘cause  what it tells us is that if we want to improve   our outcomes for the children and young people  that we see, we really need to do more in-session   exposure. And actually, what it tells us is  maybe adding these additional techniques like   relaxation, or cognitive restructuring, perhaps,  actually may impact on how effective exposure is,   and we don’t know why that is. It could be  that it’s just not leaving enough time to   do good exposure, and we know that the  more exposure that is done in session,   the better the outcomes the child will  have. We don’t really know why that is,   but we do know that when relaxation is  added, actually the effect sizes are weaker. There’s another study also conducted by Peris  and colleagues, and that showed that better   outcomes were actually produced when the child and  Therapist conducted more challenging exposure. So,   we’ll talk later about, kind of, starting off  with easier exposures and, kind of, moving to more   difficult ones, but the more the child challenged  or faced harder situations on their hierarchy of   fears, the better the child did in treatment and  the greater reduction in anxiety. So, this is,   kind of, also some more evidence to that idea  that the more extra stuff you add in-session,   the more anxiety management techniques that you  might use, actually the less time that leaves you   for exposure. And we know that you need – we need  to have those harder, more challenging, exposure   sessions to get good – get better outcomes. So,  really what this does suggest is that treatment   that includes more in-session exposures and  perhaps less of a focus on those other strategies,   might be more effective for getting good  outcomes for children and young people. So – and about – the research was really telling  us that exposure is considered central and when   you ask a lot of Clinicians or Academics about  this topic, they’ll say that exposure is probably   a pretty critical ingredient, but yet, there’s  actually really limited research on the technique   on its own. So, I’ve been talking about the fact  that the treatment tends to evaluate packages   altogether, rather than the specific techniques.  We can pull them apart using our systematic   reviews, like in the research I just talked about,  but actually, there’s really limited research just   using the technique on its own of exposure,  specifically in young people with anxiety. We also know that few children with anxiety  disorders receive evidence-based care.   So, we know from the research that, actually –  some research that we conducted in our team was   a community study in Australia showing that  children who sought help for their anxiety,   only a third of them had received cognitive  behavioural techniques or evidence-based care.   And we asked them, also, kind of, what treatment  they received, and this was relying on families’   and children’s memory, but only 5% of them  actually recalled receiving exposure of any type,   when the Therapist helped them to face their  fears, kind of, in a systematic and planned way. So, this is really interesting in terms of its  use. Even though we know that it is an effective   technique, people are finding it – Clinicians  are finding it hard to deliver it. They tended to   report, the parents in the study, that  they received a lot of other treatments,   like mindfulness, and a range of other supportive  techniques, but less on exposure, and we know that   strategies like mindfulness actually have limited  efficacy in children and teenagers. Even though we   know that they work well with adults, because of  the different cognitive development of children   and young people, mindfulness is something  that is not as effective as it is in adults,   at least in terms of the effect sizes that are  delivered, particularly in reducing anxiety.   This really highlights a gap between science  and practice, even we know that anxiety – that   anxiety’s reduced through exposure, that it’s not  being delivered as much in community practice. So, let’s talk a little bit about what exposure  is, and I’ve been mentioning it a lot so far,   but let’s talk a little bit more about what it  is. So, it’s really confronting fears in a planned   way, in a systematic way. At least in therapy, we,  kind of, do it in that systematic and planned way,   and there are lots of different variations of  way that exposure is used, a lot of different   variations. We conducted a review very recently  and looked at the literature in how exposure is   delivered, and there are huge amounts of variation  in what people call exposure. But I’ve, kind of,   listed them here, that sometimes it’s in vivo,  which is face-to-face, so the Therapist and the   child, or the parent and the child, doing – facing  their fear in a situation. So, it might be a child   facing a dog, approaching a dog, or doing a  speech in class, that’s an in vivo exposure. Then, in contrast, sometimes it’s really hard  to set up exposures that are face-to-face or,   kind of, in real life, so we do imaginal  exposures, as well, where it’s just getting   the child to face the, sort of – imagine the  situation and think about it, and getting them   to really visualise it and immerse themselves in  it in a, kind of, gradual way if the – facing the   situation’s either too hard or too difficult,  or to, kind of, schedule or co-ordinate. We can do exposures in a graded way, or in a  random way. So, graded is that you can step it up,   doing – facing the feared situation with  easier steps first, moving up to harder steps,   or it could be random, and we don’t actually have  any evidence over which is more effective. We   think that perhaps they’re both just as effective  as each other, and maybe even random, which is,   kind of, just selecting any level. There  might be some benefits for that as well, but   for children and young people, having control  over it or doing it in a graded way might actually   increase engagement, or be less likely that – for  the child or the parent to drop out of therapy.   So, most of the time, therapy is delivered – or  exposure therapy’s delivered in a graded way. We can use additional strategies. Exposure  can be done just facing the situation,   without any cognitive restructuring  or without any relaxation,   or you can add additional strategies. But what  we know from the research is, potentially,   that these additional strategies might impact.  We don’t really know why at this point,   we can add some theories about it, but adding  these additional strategies might impact on it. We’re doing some research at the moment  trying to look at that, sort of, you know,   when you add cue reminders perhaps,  or when you increase the expectancy   of violation or, you know, rehearse what it is  that the child’s worried about happening and,   kind of, checking in whether or  not that happened during exposure.   We’re looking at whether or not those, kind of,  additional strategies of cognitive restructuring,   relaxation, as well, whether that actually impacts  on the efficacy of exposure treatment. We’re   working on that at the moment, so perhaps  we’ll come back to you on that research. Also, kind of, doing it with or without  deliberate response prevention, and it – treatment   for e – obsessive compulsive disorders, OCD,  that’s anxiety – very similar with those   obsessions and compulsions, that exposure tends to  be done with deliberate response prevention. So,   where the child is asked to face the situation,  but without doing their usual compulsions. So,   it might be getting their hands dirty and  then, deliberately not washing your hands,   even though that might be a usual thing  that we do in real life, deliberately not   doing that prevention of – reducing the anxiety,   and you’re letting them sit with that  worried thought and sitting with the anxiety. With or without modelling. Exposures done  differently, whether the Therapist is modelling   how to do it first, or the parent perhaps, is  another way of varying the type of exposure.   With or without technology. There’s a lot of  treatments, I’m working on one at the moment,   looking at exposure treatment delivered  through technology and digital treatments.   Different studies have also looked at  with or without eye movements as well,   in – particularly in post-traumatic stress,  another way of varying the type of exposure,   eye movement desensitisation. That can be  weekly or intensive exposure therapy, as well. There’s a lot of great research  coming out looking at mass exposure,   so doing it all in one. We’re, kind of, used  to therapy which is weekly, one hour a week,   but actually, intensive therapy can work much more  quickly if you do it all in one go. But often,   that’s harder to co-ordinate and doesn’t  necessarily fit with funding models, but we   know that intensive therapy works effectively,  as well. It can be in-session or done at home. Alright, so how does it work? Exposure therapy  was really – it was originally developed from   the principles of associative learning. There’s  been lots of different theories that have been   used to try and explain why exposure works. The  initial focus on extinction learning, that idea   a young person, kind of, has that habituation  that you get used to the fear and habituate to   that fear, and exposure allows that person  to habituate to that fear of emotion,   sorry, that emotion of fear.  Can be fear of emotion, as well.   Others have said, too, that the mechanism  behind it might be that it actually helps a   young person to disconfirm their beliefs about  the situation. So, kind of, facing the fear   lets a – the young person know that what they  thought was going to happen is not as likely. However, more recently, there’s – the inhibitory  learning theory model has proposed another   slight – a different approach, in that exposure’s  successful because it establishes new memories   about the feared object or the situation,  that, kind of, competes with old memories. So,   it’s that idea that, you know, the old memory  doesn’t actually go away, but it just weakens   over time and then, with exposure, actually helps  to create a new memory that competes with that old   memory. So – well, this theory really helps to  explain relapse of fear as well, why these – why   once you’ve done therapy with a child and  perhaps they go through a difficult transition,   going to high school or have a stressful event,  or going through puberty, that fear might relapse. So, this theory does nicely help to explain why  there might be that relapse of fear, and that that   old memory is always there, but a new memory has  been re – doesn’t replace the old memory but it,   kind of, runs alongside of it. And the idea  of exposure strengthening that new memory,   and the more practice you do, the  stronger that memory has been. So,   I’ve been using these – this rationale,  really, to explain it to young people,   and it helps them to understand why they’re doing  exposure, that the more practice they do, that’s   not just doing it once, but they really need to,  kind of, practice and strengthen that new memory. So, let’s talk about why – what the barriers are  to exposure. If it is such an effective technique,   why are people not using it? I’ve, kind of,  hinted to some of this at the beginning,   but let’s talk about it. There are common beliefs  and misconceptions. So, I’ve heard – we’ve done   a bit of research with Clinicians, asking them  and asking parents about their use of exposure,   what stops them, what are the barriers, what  makes it easy, what makes it so difficult? And Therapists have told us that  it’s – particularly for adolescents   and any – even children, as – younger  children as well, but it is really hard,   sometimes, to engage young people in  therapy. They don’t want to be there,   they – this is a weird scenario.  They don’t – it’s not a usual setup. Usually when they’re one-on-one having, kind  of, deep, meaningful conversations, they’re in   trouble with the Principal at school, or they’re  having an intense conversation with their parents,   it’s not usually how things work, kind of,  kids and adults facing off in a therapy. So,   it is a weird situation for children, and  it is really hard to engage young people   in therapy in this way that’s been  traditionally developed for adults. And so, Therapists have told us that they’re  scared of actually doing exposure because   they’re worried about engagement and alliance  with the young person and they’re worried   that if they push them to do something that  makes them scared, that they won’t come back.   They’re worried that it might impact on that  alliance, the child won’t like them if they   make them scared. They’re also worried, too,  that there’s a lot of other comorbidities. If a child presents with a lot of fears and  there’s also depression or eating – body   image issues that – or there’s so many  comorbidities that really – you know,   “The research has only been conducted  with kids with anxiety problems,   the research isn’t really a good fit for  my client. So, I’m not going to use the   research evidence because it doesn’t fit for  my – for the young person that I’m seeing.” Also concerns around doing exposure for  more generalised worries, that children with   what we refer to as generalised anxiety, it’s,  kind of, worrying about everything, worrying about   school performance, about their friendships,  about what’s happening in the world. Kind of,   just that worrying about everything, that you  can’t do exposure with those types of anxieties, a   common misconception I’ll talk about in a minute.  And also, a lot of concern around using exposure   in children with trauma backgrounds, if they PTSD  or have experienced trauma in the past, that using   exposure – is the belief that it’s not okay to  use exposure in children with trauma backgrounds. So, let’s have a look at what the research says  about all of those misconceptions. There’s still   a lot of work that really needs to be done in  this area, but from the research we have so far,   we know that alliance and engagement is actually  stronger in therapies that include exposure.   This is some work done by Edna Foa and also Carly  Johnco, showing that engagement is really strong   when we know – when Therapists use treatments  that work and you can get change quickly, that   actually, alliance and engagement is stronger than  – and this – these studies compared client-centred   therapy. So, it wasn’t – it was a really  client-focused therapy, but actually, engagement   and alliance was stronger with exposure therapy.  We also know that exposures work with GAD. In a study I conducted with my team,   actually exposure-based therapies were even  more effective than for separation anxiety.   They work well, if not better, compared to  other anxiety disorders, and we’ll talk about   some – later, some other strategies that  can be used for those generalised worries. As for the question of a comorbidity, we know that  particularly for depression comorbidity, it can   impact on the young person’s end-state following  exposure-based therapy. So, there’s still – if   you have depression, they’re still more likely to  be severe – more severe at the end of treatment,   but we know that the rate of change is just as  quick as those children without depression. So,   the rate of change is similar. We know, also, that  ADHD doesn’t impact on the efficacy of exposure,   as well, and treatments with exposure.  So, the evidence that not using exposure   treatment when there are comorbidities  doesn’t really hold up here. And also, exposure-based therapies we  know are really effective for young people   with PTSD. They can be used effectively  to treat trauma system – trauma symptoms.   So, to me, it’s really important that, you know,  we – when we’re conducting exposure therapy,   that the young person is safe and that any  therapy that is delivered doesn’t place the   young person in a situation in which they are  in danger. But when that is done sensitively,   we know that exposure therapy is effective, and  having a trauma background shouldn’t exclude you   from evidence-based therapies and really,  that if we, kind of, we make those choices   that not delivering exposure-based therapies  for young people with trauma backgrounds,   they’re not receiving evidence-based  therapies and they’re missing out. Alright, so, where do we go wrong? Why is it that  we’re not delivering exposure in community, and   why is it not, kind of, working as well, perhaps,  when you are delivering exposure? So, I think,   kind of, one of the issues is that perhaps  we’re trying to deliver exposure or introduce   it too late in the session. Often, there’s a  lot of strategies that are delivered first,   you know, often, in treatment packages, there’s  a lot of introduction of coping strategies,   relaxation, problem-solving, and then, actually,  we don’t introduce exposure until later on in   therapy. But what we know, actually, is that it’s  the exposure bit that starts to deliver change. And actually, I want to tell you about a programme  my colleagues and I are developing at the moment,   Deanna Francis, for children with reading  difficulties. We were trying to target   reading difficulties and anxiety at the same  time, so we’d spend each time – each week in   the therapy session focusing on both a child’s  reading difficulties with, kind of, a package,   was addressing their reading, as well as  their fear of anxiety. And interestingly,   in our pilot versions of this programme, we  thought we wanted to build the child’s skill   first before that we started getting them to  read in front of others, and we wanted to,   kind of, establish these new positive  memories rather than, potentially,   getting them to read awkwardly in front  of others, to have a negative experience. So, we did this, but what we found – we  found really great effects on their reading,   but we didn’t shift their anxiety.  We, kind of, waited too late,   and this is what we think happened, is that we,  kind of, focused on the other coping strategies   and they didn’t get sufficient time in the  therapy sessions to actually practice their   fear of reading and their worries. So, what  we did is we shifted the programme around and   introduced exposures much earlier on, and then,  we started to get really great shifts in anxiety,   as well. So, lessons learnt, we  don’t want to leave it too late. One of the other issues is around – Therapists  might, kind of, introduce the idea of exposure   and start with the easy situations, the  situations the child’s comfortable with,   that might be a little bit challenging  but not too much, and they, kind of,   gradually move up to the challenging ones. But if  you’ve, kind of, got a limited number of sessions,   either you’re limited by, kind of, the  practice that you’re in, or the funding model,   then, you know, by the time you get up  to the more challenging exposures, you,   kind of, maybe run out of time, or maybe that  other issues might start to hijack the sessions. So, a child might, you know, come in with other  issues and then, you may not ever get to the   challenging situations. So, a child might leave  the therapy without actually having addressed   those challenging situations. And as I mentioned,  that study before looking at the long-term   efficacy of CBT treatments by Tara Peris,  and she showed that when Therapists reported   spending more time on those difficult, challenging  exposures, so, kind of, mild to moderate ones,   rather than the easy ones, there were better  outcomes [audio cuts out – 2642] – to remember. Often Therapists also might not  pick up situation – or might,   kind of, pick situations, sorry, that  the child’s facing that doesn’t actually   approach the situation, or doesn’t  actually face the situation, so,   kind of, doesn’t target the fear. So, you  know, it might be that a child’s fearful of   making a mistake, reading in class, and so, they  practice answering questions in class, but don’t   actually ever deliberately make a mistake.  So, they’re not actually really facing the   situation that they’re scared of. So, they don’t  actually get to create a new memory about, you   know, deliberately making a mistake or being able  to, kind of – sorry, yeah, being able to create   a new memory about making a mistake so that,  then, they can, you know, have different – a   different view of that, or different memory of  it. So, what we actually do is getting – get   children to deliberately make a mistake, to  see if they can handle it, [audio cuts out   45] – we do in our exposure. So, making  sure that you’re picking a situation where the   child’s confronting the fear. We think that  might be one place where people go wrong. And finally, what our – in some of the research  that we’ve been doing with parents and young   people, they’ve told us a lot about their lived  experience of exposure therapy and doing homework.   And often, they feel really ill-equipped when  they walk out of the session, to actually do   exposure on their own. Parents feel really at  a loss without the Therapist there, and young   people don’t really know what role the parents  have to play and what their role is. Parents,   too, have told us that, that they don’t know  what to do. Even though we, kind of, go through   structured information for parents, often  that they feel like they’re not as equipped   and they’re not sure how they should be  best supporting their – the young person.