behaviorally inhibited temperament behaviour modification brave story exposure ladder fears

My daughter spoke during a birthday party, so why don’t I feel good about it?

My daughter turned 3 years old this past summer. We had virtual “parties” with her paternal relatives and in-person celebrations with her maternal bubble during the pandemic. We sang Happy Birthday and blew out candles many times. She loved it and continues to play “birthday” many months later. Two weeks after her birthday, we were invited to a socially distant outdoor gathering for my friend’s child’s birthday. I thought this would be a good opportunity for my daughter to experience a social gathering with no pressure to play with other kids or do anything at all other than stay by my side to maintain distance from other people. And that is how I should have left it. But…

…I decided to take the opportunity to practice giving something to another child (present) and saying a socially expected phrase “happy birthday, [Friend]”. I did not think she would do these things at the party, but we used the lead up to the party to practice these acts during play in our home. I wrote a story and even conducted a small exposure ladder which included visiting the front yard of the friend’s house the day before the party and stopping to have ice-cream on the sidewalk to increase familiarity with the house (without seeing any people) and provide a positive association with the location (ice cream!). I suspected that the lure of a special treat on the day of the party would be a strong motivator for her to try to speak.

At that time, my daughter only spoke freely to her special bubble of people: parents, maternal grandparents, and little cousin. She spoke with restrictions to a handful of other relatives. She did not choose to speak to anyone else. She would, on occasion, say short statements with my prompting like “hello” and “how are you?” to neighbours that we pass on the sidewalk with the promise of a chocolate chip treat.

If this friend had not had a birthday party, I would not have sought out this opportunity. Even at the time, I felt this was too soon to push social speaking or interacting with another child that we saw infrequently. However, I tried to channel our psychologist, and I think she would have encouraged me to take advantage of the opportunity (especially since I had time to write a story and do a small exposure ladder). When we arrived at the party, my daughter held the present and I encouraged her to pass it to the birthday child. She did so but was clearly nervous. I prompted her to say, “happy birthday” which she was able to blurt out and then we immediately picked a treat from the table. For the rest of the event, my daughter stood beside my chair and watched the proceedings unfold (a bunch of adults sitting at a distance chatting about work and life). At some point I realized she was a bit more frozen than I expected and when I touched her arm, I realized she was slightly shaking. I knew this was too much and reminded her that we were going to see her cousin afterwards and we would leave soon. After a couple of minutes, I told her we were leaving and suddenly she blurted, “I want another cookie!”. The fact that she was able to speak when she was clearly distraught was surprising. Cookies are a powerful motivator, apparently.

At the time, I felt like this event had been a huge success. My daughter completed the socially appropriate act of speaking and giving a birthday gift and was thrilled to have a treat as her reward. I praised her after the event, and she had a big smile on her face. But, deep in my gut, I did not feel good about the experience; something did not sit right. I felt that I had coerced my daughter into playing the role of a puppet. She knew that by performing, she would get treats and praise from Mommy. She may have even felt that my love for her hinged on performing this incredibly difficult and fearful task. How horrible. My love for her is unconditional, but what I know does not matter; what matters is how she interprets my actions.

After much reflection, I realize that this birthday party was me pushing my daughter to do something that she did not want to do and did not need to do. Why did I think this was a good opportunity? Why did I think this was the right thing to do? I have a child who is clearly behaving atypically (not talking to others), and sometimes I feel like I am on the edge of the normal circle looking in and I feel pressure to be making active strides to get into the circle all the time. It was my own feelings of doubt about what I was doing with my daughter, my own feelings of wanting to fit in with the group, my own motivation of making my family appear normal to others, my own interpretation of what my psychologist might have recommended that pushed me to push my daughter. And I regret it.

What makes this situation different from all the other brave stories, exposure ladders, and fear-based activities that we have worked on over the past year? The other stories and ladders and actions were generally motivated by a (fearful) reality that we had to face: COVID-19, I had a doctor’s appointment for a mole removal on my face, our friend’s struggle with a special needs “explosive child” and a toddler, we were trapped in our condo’s elevator which created a phobia, etc. When I reflect on how I have encouraged bravery, it is to face things that we must face even when we are scared. It is about explaining the unknown and making it known. It always felt like we were facing things together and coming away stronger than before. It was never about exposing my daughter to fearful experiences to alleviate my own concerns of being atypical, until this birthday.

Of course, I want my daughter to be able to have good mental health and strategies to cope with feelings of anxiety. I hope that one day social situations and speaking will cause lower levels of anxiety, altogether, but pushing too much too soon will not get us there. My goals for my daughter speaking and engaging in social behaviours are long-term. They do not fit with the traditional age-requirements of our society where all preschools and classes are drop-off by 3 years old. I need to get creative. I need to find or make my own solutions that fit our life. It will be my advocacy and ingenuity that will create the environment my daughter needs to thrive such that we reach those long-term goals without sacrificing our relationship.

In my next post, I will discuss scripts I wrote for my sister to help her toddler make transitions.

behaviorally inhibited temperament exposure ladder

My struggle with balancing anxiety treatment and life

Sometimes dealing with anxiety (or a behaviorally inhibited temperament) can feel like a losing battle. You finally address one fear and five more pop up. There are many days when I wonder, “how much fear-facing is too much?” How should I weigh “encouraging bravery and working on fears” with “accepting my child as-is and building a positive, loving relationship”? Experts would say those two goals are the same and do not need to be balanced, especially when you look at the big picture of a person’s life. But every parent of an inhibited child knows that those two goals come into conflict daily. Crying, tantrums, resistance, and abject terror on your child’s face are just some of the possible outcomes of facing fears, even in controlled environments. These behaviours are physically and emotionally exhausting for both the caretaker and the child.

Facing fears is extremely hard. I often wonder how many psychologists and therapists have used cognitive behavioural therapy and exposure therapy to face their own worst fears? I first learned about this treatment when I used both therapies for a medical condition and associated phobia in my twenties. I spent 2 hours per day on meditation, mindfulness and thought records, and then worked on the exposure ladder. I chose each step and set the timeline and rewards. It was incredibly difficult and time-consuming. For the specific phobia, working through the exposure ladder was one of the hardest things I have ever done. I know the physical and emotional toll it takes to face a fear using these methods. This is one of the reasons why I balk at the idea of continuous and constant exposure for inhibited children.

I mentioned my daughter’s tendency to avoid busy play-gyms to the psychologist and she told me, “oh no, you can’t avoid play gyms. You need to go to them.” And I thought, why? I hate them too! They are loud and over-stimulating. Many of the children are poorly behaved with caregivers sitting on the sidelines with their faces in phones ignoring their child who is grabbing toys from anyone within reach. As the gym filled up with more and more children, my daughter stopped moving, looked at the door and walked towards it. I would have had to physically restrain her and have her cry to keep her in the gym (or reward her a lot!). Then, would I have to decide how long before we were “exposed” enough? I could set up an exposure ladder with rewards to achieve a cry-free extended play-gym experience. But is this worth it? I don’t know. I know that I do not like big groups of my peers at busy bars and pubs (the adult equivalent to play-gym?). I do not want to go to a party and make small talk for hours. I am happy and content with my life. I love being a mom and I am a good scientist. I like getting together with close friends. I like being with bigger groups of friends and family on special occasions. I got to “work” my friend’s wedding and I had a blast. I felt useful while still being in the hustle and bustle celebrating my friend’s big day without having to make small talk continuously. I help others and get a lot of joy out of my interests like baking and sewing. So why does my 22-month-old need to survive play gym?

The psychologist would probably agree that there needs to be balance, but when I read information about anxiety, there never seems to be a balance: the recommendation is exposure, exposure, exposure. And the research seems to support this. Researchers have shown that anxious rat pups (baby rats) exposed to novelty early in life became less anxious adult rats compared with control (unexposed) pups. A human child might be less inhibited as an adult with forced, continuous exposure therapy in early life, but at what cost? I do not think science and research has an answer for me. Those mother rats never had to endure tantrums from their exposed pups, and those rat pups did not cry when the researchers picked them up and removed them from their mom (or maybe they did!). And when they were adult rats, we have no idea if they still “loved” their mom and had a positive attachment to their mom. Unlike mother rats, human parents weigh the benefits and consequences to find a solution that works for their family. This might mean exposure, exposure, exposure. But it also might mean some exposure and some avoidance to make space for other non-fear related positive child-parent interactions because there are only so many hours in the day.

The bias underlying anxiety treatment (and the associated research) is that uninhibited, social traits are preferred over all other personality traits [more info]. As an introverted, inhibited, shy person, that slant feels wrong to me. Our strange existence in the pandemic has given me pause to reflect on anxiety treatment and exposure and I am still working towards finding a balance for my daughter and me. I found great success with the elevator exposure ladder, but would I want to do this every day for every fear? No. I am taking a page from Ross Greene’s book Raising Human Beings, and prioritizing my daughter’s fears. I do not need to tackle them all. She does not need to tackle them all.

In my next post I discuss behaviour modification and my mostly hate relationship with this ubiquitous parenting strategy.

The Good in Inhibited Children

After I wrote this post, I started reading an evidence-based book, The Orchid and the Dandelion by W. Thomas Boyce. The author weaves his personal family history with research findings related to inhibited (orchid) and uninhibited (dandelion) children. He creates a story that describes the challenges of having an inhibited temperament and the unique opportunities to nurture great beauty in the child. It is the first writing that I have come across that explicitly states research-backed positive traits of an “orchid” child. I will provide an update when I finish the book.

brave story exposure ladder

Brave stories and exposure ladders for anxiety: a fear of the bike trailer

After great success conquering my daughter’s elevator fear, I was eager to try this method again. Conveniently, when you are around two 2-year-olds, there is always a fear that can be addressed. This is the story of how I put my 2-year-old niece in a bike trailer and thought everything was going great until an extremely fearful tantrum showed me it was not going great at all and I needed to slow waaaaaay down.

The weather was getting better and better and I wanted to start biking my daughter to the beach and forest. My husband and I decided to take my niece with us on our forest adventure. My husband rode his bike and I rode our e-bike pulling a double bike trailer to my sister’s house. I picked up my niece and started talking enthusiastically about going to “Turtle Pond” (a forested park with a pond that is a 5-minute bike ride from our house). My daughter has always loved the bike trailer and bike seat and she was sitting patiently in the trailer when I popped my niece in and away we rode. We had a great time playing in the forest. After dealing with my daughter’s meltdown right before we needed to leave Turtle Pond, I was trying to get the kids buckled in as quickly as possible so as not to be late for nap time. My niece was having none of it. She physically resisted (which is hard because she is tiny and slight with minimal muscle strength). I could have physically forced her into the trailer, but that is a parenting method I try to use very rarely. I stopped, pulled back, and talked to her about going to see her mommy. She said she wanted to drive back. I explained there was no car; this was the only way home. She continued to resist. Eventually, I think she misunderstood what I said and was somehow convinced to get into the trailer, but as soon as I secured the buckles she started screaming. The look of desperation and fear on her face was unmistakable. She screamed to be let out. And of course, just our luck, it was also raining so I zipped up the rain cover on the trailer making it even more of a constrained box. Thankfully, my daughter did not break down through all of this and sat their quietly (her meltdown came later!). Anyway, I looked at my husband with pleading eyes, thoughts whirling around: I do not want to bike this scared child; she is terrified; it is almost nap time, she’s probably tired and I have no other way of getting her home in a timely fashion. My husband convinced me to start biking and immediately she calmed down. Ok, I thought, maybe she did not know what the bike trailer was all about. This is fine. My husband played “peek-a-boo” with her during the ride home and got some smiles. I dropped her off and explained what happened to my sister in case my niece needed to “release her emotional backpack” in the form of a good cry again.

You can guess what happened the next time my husband and I tried to take my niece on an adventure. No dice. I had already told my husband there is no way I was going to strap a screaming Niece into the bike trailer. When there is so much fear going on, that fear needs to be addressed on her timeline, not mine. I do not agree with “sink or swim” methods as I think this can lead to phobias and I think it is disrespectful of the child as a human being [more info]. Instead, I took a step back and realized I needed to make a Brave Bike Trailer Story and exposure ladder. I also needed to figure out what exactly was fearful about the bike trailer from a limited-vocabulary, minimalist speaking 2 year old. Luckily, these things became evident one day during a walk. My niece said to my sister “tight” and “bump”. In a bit of context, we discovered that my niece was afraid of bumps in the bike trailer and the tightness/constraint of the straps. I included these two specific issues in the brave story (at the time, I knew the straps were an issue but I didn’t realize the word “tight” was related which is why it is not included in the story).

We read the story and started the exposure ladder:

  1. Read personalized story (reward: none)
  2. Bring bike trailer to front door for investigative play (reward: verbal encouragement)
  3. Bring bike trailer on walk to park for investigative play (reward: verbal encouragement)
  4. Offer ride in bike trailer used as a stroller (no buckles) (reward: book in trailer)
  5. Go over bumps in stroller-mode (no buckles) (reward: verbal encouragement)
  6. Ride in bike trailer for adventure with Mommy (reward: book in trailer)
  7. Goal: Ride in bike trailer for adventure with Auntie A (reward: book in trailer)

We stalled on step 2! Unlike my daughter, my niece had absolutely no interest in investigating the bike trailer and playing with the zippers and buckles. My daughter still spends many minutes sitting in the trailer buckling in her stuffed animal and zipping the zippers and asks to play in the trailer every time we use it. My niece could not have cared less about the trailer. I tried step 3 and there was minimal interest from my niece. She did not care about this trailer coming with us to the local park; she cared more about looking for bugs than zipping zippers. The next idea I had was to encourage her to sit in the bike trailer for a snack and I rewarded her with a chocolate chip. This worked, but I did not want to make this a habit since I do not allow my daughter to eat in the bike trailer. From this non-step, I discovered that my niece would get in the trailer under the right circumstances and she feels proud of herself for accomplishing brave tasks. Her smile was huge, and she clapped when I stated how brave she was for sitting in the bike trailer even when she felt scared.

My next idea was to use books as an enticement into the trailer. Unlike my daughter, my niece LOVES books. All she wants to do is have someone read books to her and she is also thrilled to flip through books alone. So, I collected a few small board books and put them into the trailer on our next walk. My niece walked along without so much as a glance towards the trailer. My daughter saw the new books and jumped into the trailer. This was finally the scenario that convinced my niece to get into the trailer. I decided not to secure the straps and just slowly pushed the trailer with the kids looking at the books. At the end of the walk, I specifically pushed it over some small “off-road” grassy bumps. I ended up combining steps 4 and 5 and we had success. I found new books for step 6, and with a beach destination my niece was excited. We set up the bike trailer, showed her the books, explained where we were going, and she jumped right in! We finished off the exposure ladder by leaving Mommy at home and now my daughter and niece happily ride in the bike trailer together reading books and singing songs.

I am relieved I did not force a screaming Niece into the bike trailer. Taking a step back and seeing the situation through her eyes and addressing her fears allowed us to move forward in a positive way that ended up right where I wanted her (able to ride in the bike trailer) and, more importantly, gave her a sense of bravery and accomplishment that we can now reference for future fears. The whole process took about 2 weeks with no tears and was not intensive (i.e. I did not read the story or implement the exposure ladder steps daily). This is an example of why you do not have to write the perfect story or make the perfect exposure ladder to get positive results. Give it your best first shot and then adapt as you learn new information from your child. However, developing a plan with thoughtful steps is important to prevent you from jumping too far ahead and going faster than the child’s pace.

In my next post, I will describe the behaviorally inhibited temperament, anxiety and the numerous behaviours I noticed in my daughter that were “different”.

Sink or Swim

I do not agree with using sink-or-swim methods on children for fears. I think the messages to children from sink or swim methods are negative and include:

  • The adult’s needs are most important.
  • The adult doesn’t care about my needs.
  • The adult does not know my concerns.
  • The adult is not going to take time to find out about my concerns.
  • The adult is bigger than me and can physically control me.
  • There is nothing I can do to stop the adult.

So even with a successful sink or swim method (i.e. the child eventually gets into the bike trailer without screaming/crying), the messages that the adult is sending are negative, aggressive, and controlling. Whereas, in a thoughtful, planned gradual exposure method based on the child’s fears and concerns, the messages are much more positive

  • The adult hears me.
  • The adult wants to help me.
  • I am scared and it’s okay to be scared.
  • I am brave.
  • I can do things all by myself.

We are all such capable adults that it can be hard to slow our life down and move at a child’s pace. But whenever we can take time, the results are so rewarding and go far beyond just conquering one fear. The child will develop greater confidence as their bravery increases as they face more fears when they feel in control of the progress.

The researcher in me is also curious if a person implementing a sink or swim method would find “success” any sooner than using a gradual exposure “planned” method. When you look at the grand scheme of life, two weeks is quite fast to go from fear of a bike trailer to happily riding for adventures!

brave story exposure ladder

Brave stories and exposure ladders for anxiety: a fear of elevators

I discussed explanatory stories in my previous post. Now, I will present the more common type of story used for anxiety: brave stories. A brave story is about a situation, person, object, or activity about which a specific child is frightened. I will use the word “situation” in the rest of the post in place of person, object, and activity for simplicity. A brave story is used in combination with an achievable goal that allows the child to better cope with the anxiety or decrease the severity of anxiety associated with the situation. This differs from the explanatory story, which does not have a child-led goal. The explanatory story is about a situation that exists over which a child has little or no control and may be inherently scary (sibling behaviour, COVID-19) but could also be mundane (wedding). The brave story involves the child taking control, taking action and feeling brave and confident, despite feelings of anxiety. The situation is not inherently scary.

Brave stories supplement direct action. The direct action is defined as rungs on an exposure ladder. Exposure ladders are an exercise in cognitive behavioural therapy. Each rung is defined explicitly, and the child is encouraged and supported by caregivers to reach that rung. Rewards may be used after reaching particularly challenging rungs, just as you might reward yourself with drink, food, clothing, or vacations for reaching a goal. Rewarding is not bribing. Bribes are used to convince a child to do something that you want them to do (on your timeline) and may have nothing to do with feelings of anxiety (i.e. a child is tired and does not want to get into their car seat. Offering a treat for getting in the car seat is a bribe). Rewards are for a child doing something (on their timeline) that elicits a sense of pride, despite feelings of fear (i.e. a child is afraid of the car seat and after explicit steps of exposure to the car seat is rewarded with a treat for getting in the car seat, despite feelings of anxiety). The distinction between bribes and rewards can feel fuzzy but it becomes clear when you work through an exposure ladder with your child. I can see the fear written on my child’s face when she does something scary and afterwards, she is beaming and proud of herself and asks for a special treat and is motivated to try again. Alternatively, I can see that there is no fear but just tiredness, hunger, or discomfort about getting in the car seat quickly on my timeline so giving a treat is a bribe.

One of my first brave stories was inspired by my daughter’s increasing hyper-vigilance about the elevator doors closing. Months ago, my daughter, niece, sister and I got trapped in my condo building’s elevator. We were trapped for about 30 minutes while we waited for the fire department to rescue us. My sister and I maintained calm speaking voices, video chatted with grandparents and sang songs. But my daughter was clearly terrified. She reverted into her non-verbal, limp rag-doll state. After the event, we got her running around outside and she seemed okay. She also played “elevator rescue” with my husband for weeks afterwards in our home. A few weeks ago, as I was trying to maneuver a bike into the elevator, the bike fell, and the doors started closing with my daughter inside the elevator and me outside. I was able to press the call button and the doors opened before they completely closed, but I could see my daughter’s terrified face. The following weeks, I noticed that my daughter became hyper-vigilant about making sure everyone got on/off the elevator without the doors starting to close. I thought her anxious behaviour would lesson over time, but it seemed to get worse, so I decided to write a Brave Elevator Story. I also created an Elevator Exposure Ladder that my daughter and I worked on over the following weeks. Before each step, I talked about what we would do.

  1. Read story
  2. Show Lisa how I can get the doors to open by pressing buttons (outside elevator)
  3. Show Lisa how I can get the doors to open by pressing buttons (inside elevator)
  4. Put Rabbit (stuffed animal) on the elevator alone and watch the doors close. Talk about how Rabbit is safe. Mommy pushes call button and we give Rabbit a hug. Repeat.
  5. Mommy goes on elevator alone while Lisa waits outside the elevator. Lisa watches the doors close and Mommy opens the doors again by pushing the buttons (Lisa is praised for bravery and receives a sticker). Repeat.
  6. Mommy goes on elevator alone while Lisa waits outside the elevator and Mommy rides the elevator one floor down. When the doors open, Mommy calls out to Lisa that Mommy is still on the elevator. Mommy rides back up to the floor where Lisa is waiting. (Lisa is praised for bravery and receives a sticker). Repeat.
  7. Lisa goes on the elevator alone and watches the doors close and Mommy pushes the buttons outside to open the doors. (Lisa is praised for bravery and receives a sticker).
  8. Final Goal: Lisa goes on the elevator alone and watches the doors close and Daddy pushes the elevator call button on another floor. Lisa is alone on the elevator when it moves to the next floor. The doors open and Lisa sees Daddy at the new floor. (Lisa is praised for bravery and receives a sticker). Repeat.

I did not think my daughter would reach the goal. This is not the best way to start an exposure ladder. It would be much better to have confidence that your child will succeed. I created the exposure ladder based on my own idea of logical, sequential steps but without a lot of thought of my daughter’s age (2.5 years old) and developmental stage. In hindsight, I should have given this greater consideration and with a different child, I might have stopped the ladder at a lower point. Ultimately, I thought there was so much fear around the elevator that my daughter would never ride the elevator alone (at this age). But isn’t the point to alleviate some of those fears? Anyway, without more thought, I blazed ahead with the plan.

The story intrigued my daughter and we talked about the elevator a few times after reading the story, reinforcing that the elevator was safe and that Mommy can always open the doors (ok, except the freak time when it stalls and you have to wait for the fire department but that’s pretty rare and I decided I was not going to address that in this round of story-exposure-ladder action). I waited for a week or so of reading the story before starting the ladder. Each step was refused by my daughter. I would smile and say, ok, maybe next time we’ll try that. EVERY time, my daughter would wait a couple of seconds and then say, “ok [let’s try it]” and we would try the step. My daughter is one of those kids that loves to please (me). She wants to do what I suggest and has a rule-follower type personality, so this often works to my advantage. I stay enthusiastic, upbeat, and encouraging and eventually my daughter usually complies. Not everyone is so easy (as we will see in another example with my niece in my next post). But her reactions in steps 2-5 gave me more and more confidence that we could achieve the next step. That all stopped at step 7 though. I still hesitated to push her to step 8. Was this step really necessary? Does a 2.5-year-old need to ride the elevator alone? I decided I wasn’t going to push it, but one day I accidentally pressed the wrong floor button. As we were going to the wrong floor, I said, “I could jump out and you could ride the elevator all by yourself to our floor and I’ll meet you up there”. She said, “ok”, without much thought and everything happened too fast to change our minds. Away she went in the elevator while I ran like never before up the stairs to get there before the doors had fully opened. She came out grinning and gave me a hug. She was so proud of herself. She now asks to ride the elevator alone, so I purposely push the wrong floor button and jump out and take the stairs to meet her. Her bravery surprised me! Interestingly, through all the steps, the first few times of each step were clearly causing feelings of anxiety. Her fear was written all over her face as the doors would close, but she would always come out grinning and excited that she had done it “all by myself!”

I learned some valuable lessons from this experience.

  • My daughter is more capable than I thought!
  • When creating exposure ladders, it is important to consider age and developmental stage and to remember that every 2.5-year-old does NOT need to ride the elevator alone. My daughter experienced so many feelings of bravery from steps 4-7 and she stopped being hypervigilant about the elevator doors by step 7, so that is where I should have stopped the ladder. Step 8 was just a bonus.
  • It is okay to take breaks during the exposure ladder and regroup (I took a long break between steps 7 and 8).

Older children can participate in creating the Final Goal and the Rungs (steps) of the ladder, but for very young children, the caregiver will create the goal and ladder. If you have never worked with an exposure ladder for anxiety treatment, try it first on yourself. Pick something that truly gives you feelings of anxiety and fear. If you don’t have an anxious temperament or many fears, this may not be feasible for you. I have done an exposure ladder on my own phobia which helps me understand what my daughter will face at each step. This gives me a sense of empathy that is truly authentic! It is helpful to have an adult describe the feelings and thoughts for their own personal ladder rungs so you know what your child might be going through even though they may not be able to articulate those thoughts and feelings.

Before I started writing brave stories, I created a Dentist Exposure Ladder with the help of the child psychologist. One of the rungs on the ladder was to read a dentist story. I used Daniel Goes to the Dentist (the book based on the story from Daniel Tiger’s Neighborhood TV show) adapted by Alexandra Schwartz because it was one of the only stories that showed a simple cleaning visit (no x-rays, surgeries, teeth pulling, etc.). I saw how much this story helped my daughter think about the dentist and realized that a personal story (with specific language and images) would have been even better. The combination of Exposure Ladder and personalized Brave Story is more likely to succeed in reducing anxiety, converting an unknown situation into a known situation, and creating positive feelings of bravery in a child than either strategy in isolation.

In my next post, I will describe a Brave Story and Exposure Ladder for a bike trailer fear with a child less eager to please me!