Fear

How to Parent a Fearful Child

Helping a fearful child move forward: lessons from graded exposure therapy.

Posted Mar 19, 2020

At what age should parents be concerned about a child who asks to sleep with a night light? When seeking to differentiate normal child behavior from a behavioral health condition, one of the most important questions to ask is about functional impairment. For example, it may be rather unusual for a teenager to sleep with a night light, but this habit is likely not impairing the overall functionality of their daily life.

But for others, fearful behavior can begin to significantly impact functioning; perhaps the most noticeable being academic performance [4]. With rates of anxiety diagnoses in children steadily increasing over time [1] and over 4 million childhood anxiety diagnoses in the United States—of whom only 6 in 10 receive any form of treatment [3]—questions about differentiating normal childhood fears from early-stage childhood anxiety or phobia have been rightfully raised. Although specific phobias are less common than generalized anxiety, it is estimated that between 5% and 10% of children have a specific phobia severe enough to impact their everyday functioning [5].

If a child is experiencing a specific phobia severe enough to impair their functioning, parents should first seek qualified mental health care. Still, families of a child with a specific phobia can utilize a few at-home tactics to support their child as he or she seeks to conquer their fear. Taking cues from Acceptance and Commitment Therapy (ACT) and graded exposure therapy, this post briefly outlines a few tactics parents may employ when supporting a child who has been negatively impacted by their fears about a specific subject.

anemone123/Pixabay
Source: anemone123/Pixabay

First, parents should be open to the possibility that their child has a biopsychosocial predisposition towards their specific phobia. While the origins of the phobia may not be entirely knowable, there's no use in blaming the child's character for the symptoms. Instead, focus on the child's potential for future bravery in the presence of their fear. While parents may be tempted to provide information to their child about the irrationality of the child's specific phobia, they are unlikely to find success with this tactic. I will personally put a crisp dollar bill on the line for anyone who would like to bet that informing a child of the safety of vaccinations will remove that child's fear of needles. Instead, consider seeking to affirm the child's emotional state—without lending credence to their supporting logic.

For example, 8-year-old Jess recently developed a fear of insects that is severe enough to be functionally impairing; she is no longer willing to play outside and reacts with pale-faced fear when she notices a fly in the room. Jess's parents have told her a hundred times that insects aren't dangerous and that even a bee sting is only mildly painful. Despite her previous love of soccer, she remains inside and begins to develop a strong aversion toward any outdoor activity. Under the direction of a mental health professional, Jess's parents begin to praise even the slightest attempt at bravery—seeking to elicit more of that behavior by rewarding it with positive reinforcement. Then, they receive and affirm Jess's emotional disclosure without suggesting her fears are actually well-founded.

Jess: "If a fly lands on me, I'm going to die!"

Parent: "It's really hard to be scared! Are you OK?"

Jess: "I'm OK as long as there's no bugs."

Parent: "I can see you're really struggling with your fear right now. I'm proud of you for staying strong."

A wonderful start! But where to go next? Parents may consider seeking to implement a safe and measured at-home graded exposure therapy. The guidance of a mental health professional would be helpful in planning these activities, but let's use the prototypical fear of the dark as a template for graded exposure.

A child who has gotten into the habit of sleeping with the light on may be extremely resistant to transition directly to full darkness or even to a nightlight. In this circumstance, the assistance of a mental health professional is likely not necessary. Parents have been handling this situation since the invention of light bulbs (I assume)! However, they may need to be creative; perhaps first installing a dimmer light bulb in the child's room, then transitioning to the hallway light before finally using nightlight only. Next, parents might seek to move the night light to the hallway and finally remove the night light altogether.

This form of graded exposure therapy has been long considered the clinical standard for treating phobias (in adults too!) and shows promising evidence even when carried out in a single session [2,6,7]. In graded exposure therapy, a client is guided in constructing a "fear hierarchy" which lists their phobia-related fears from lowest (minimally anxiety-inducing) to highest (maximum anxiety). In One-Session Treatment (OST) [2,6,7], children are walked through their fear hierarchy slowly but surely until they're able to handle the maximum or near-maximum (if the peak of the hierarchy is dangerous) activity. In a prototype of a case that may require consultation of a mental health professional, Jess's anxiety hierarchy may begin with something as small as thinking about insects. A midpoint for Jess might be sitting in a room that has a fly in it. Finally, the peak of Jess's anxiety would likely be something like touching an insect. Her parents and therapist can mutually determine if reaching Jess's anxiety hierarchy peak is necessary for her unique case. After all, most people have some aversion to touching insects but don't experience functional impairment. In this case, Jess and her therapist may decide that as long as she can return to normative activities (like playing outside) without fear, there is no clinical utility in reaching peak anxiety. Jess may never be an entomologist, but she can get back on the soccer field!

Perhaps the most impressive aspect of OST is the cost-effectiveness [7]. For individuals who may not have the resources or time to engage their child with weekly mental health care, single session graded exposure shows promise [2,6]. Of course, no treatment is a cure-all and some phobias have complex, deep-rooted etiologies that may require more detailed cognitive therapy to address. However, if your child has been in treatment for phobia and you haven't noticed improvement, consider asking your child's therapist about their willingness to try graded exposure therapy. And, if your child is struggling with a phobia but has not yet received mental health care due to structural limitations, consider asking a local therapist if they would be willing to try One-Session Treatment using graded exposure therapy to a fear hierarchy. Ultimately, the qualified clinician who sees your child will be best suited to collaboratively determine a clinically indicated course of action that best suits your family's needs.

References

Bitsko, R., Holbrook, J., Ghandour, R., Blumberg, S., Visser, S., Perou, R., & Walkup, J. (2018). Epidemiology and impact of health care provider-diagnosed anxiety and depression among US children. Journal of Developmental and Behavioral Pediatrics, 39(5), 395-403. doi:10.1097/DBP.0000000000000571

Davis, T. E., Ollendick, T. H., & Öst, L.-G. (2019). One-Session Treatment of Specific Phobias in Children: Recent Developments and a Systematic Review. Annual Review of Clinical Psychology, 15(1), 233–256. doi: 10.1146/annurev-clinpsy-050718-095608

Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (2019). Prevalence and treatment of depression, anxiety, and conduct problems in US children. The Journal of Pediatrics, 206, 256-267.e3. doi:10.1016/j.jpeds.2018.09.021

Ialongo, N., Edelsohn, G., Werthamer‐Larsson, L., Crockett, L., & Kellam, S. (1995). The significance of Self‐Reported anxious symptoms in first grade children: Prediction to anxious symptoms and adaptive functioning in fifth grade. Journal of Child Psychology and Psychiatry, 36(3), 427-437. doi:10.1111/j.1469-7610.1995.tb01300.x

Kessler, R., Berglund, P., Demler, O., Jin, R., & Walters, E. (2005). Lifetime prevalence and age-of-onset distributions' of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593-602.

Ollendick, T., Ost, L., Reuterskiold, L., Costa, N., Cederlund, R., Sirbu, C., . . . Jarrett, M. (2009). One-session treatment of specific phobias in youth: A randomized clinical trial in the united states and sweden. Journal of Consulting and Clinical Psychology, 77(3), 504.

Wright, B. D., Cooper, C., Scott, A. J., Tindall, L., Ali, S., Bee, P., . . . Wilson, J. (2018). Clinical and cost-effectiveness of one-session treatment (OST) versus multisession cognitive–behavioural therapy (CBT) for specific phobias in children: Protocol for a non-inferiority randomised controlled trial. BMJ Open, 8(8), e025031. doi:10.1136/bmjopen-2018-025031