Central Therapy Strategies

Central Therapy Strategies of this Play- and Humor-Infused Exposure Therapy Approach

Build a fear ladder: Generate a list of situations or “steps” to explore the target scenario. Note that steps will involve more or less play/toys depending on the child. A variety of modalities may be used (mp3 files of noises, puppet play, parent); see manual.
Fill in ladder with trigger scenarios to re-create in session with the most tolerable situation at the bottom (e.g., play with toy toilet [low]; listen to toilet flush audio [low]; use doll on real toilet [medium]; flushing real toilet [high]).
Ask parent to rate the level of emotion the child shows or would likely show, from 0-10, for each step; rearrange as needed.**If child has little mastery of pretend/symbolic play, make play scenario as close to the actual situation as possible; e.g., form hierarchy using a real toilet

Example: Fear ladder hierarchy for blenders:

Goal	Details	Example
Select step from hierarchy	Choose a step that is challenging yet manageable Must be under the threshold for upset
Decide proximity to reality	Based on observations of pretend play skills Lower pretend play skills may require more proximity to reality	For an older child who understands pretend play, use play toilets and dolls being scared of a toy toilet in a dollhouse. For a young child who may not understand correlations, put a doll on an actual toilet
Select toys	Based on level of pretend play/proximity to reality Child preference	Play toilet, dolls, pictures of toilets, sounds of toilet flushing, real toilet. E.g., For an older child who understands pretend play, use play toilets and dolls being scared of a toy toilet in a dollhouse. For a young child who may not understand correlations, put a doll on an actual toilet
Engage in Exposures	Expose child to scenario through play Show similar emotion responses to what child shows Add humor	Make a doll go to the bathroom, flush toilet, and exhibit an emotional response similar to what the child would normally show, infusing exaggerated, silly vocalizations / gestures and lots of humor. (See Nuts and Bolts Appendix)
Repeated exposure for habituation and practice of alternative response in feared situation	To facilitate habituation and boost competence, practice the situation multiple times, addressing issues that arose	When it seems like the child is not anxious anymore about a situation or stimulus, do it a few more times to solidify the child’s non-anxious response.
Stay just under child’s threshold for upset	Challenging, yet tolerable & manageable Back off during exposure when child is fearful or exhibiting a highly emotional response Also consider adding more humor or playfulness Give child some time for response to abate Make sure to come back to the scenario, albeit potentially lower on the fear ladder.	When you notice the child getting upset about watching fireworks, go back to an unrelated activity that resulted in laughter in the past, then come back to the fear ladder.