**3.9. Social skills training**

**3.8. Exposure technique**

14 Cognitive Behavioral Therapy and Clinical Applications

others.

childhood depression treatment program [82].

The most important factor that feeds the continuous and resistant nature of childhood anxiety disorders is the avoidance behavior that the child has developed against the situation causing anxiety. Therefore, prevention of the avoidance behavior in anxiety disorders constitutes one of the most important targets of CBT in terms of treatment [49, 93]. Exposure can also be used in childhood depression even though it cannot be involved as the primary technique. Especially in the current conceptualization of activity scheduling technique, the importance of avoiding on "depresso-typic" behavior has been emphasized [94]. From such perspective, avoidance behavior feeds the continuous nature of childhood depressive behavior just as in anxiety disorders. Avoidance behavior is triggered by situations creating stress, and reinforced by the relaxation feeling afterward. Along with the avoidance, immobility, withdrawal, and inertia symptoms increase more and a vicious circle is created; as a result of such vicious circle, the child lacks the surrounding reward resources that might reduce depressive symptoms [95]. Consequently, especially if the child has started to avoid situations or activities that trigger cognitive distortions, or depression is accompanied with anxiety symptoms, exposure must be involved in the

Exposure faces the child with a situation that evokes fear in an imaginary or in vivo manner, and offers the opportunity to apply and test the skills learned during the therapy in order to cope with situations creating anxiety. This technique can be applied in systematic exposure or flooding forms, and adapted according to the developmental period of child or characteristics of the feared object/situation [73, 76]. For instance, it is not possible to carry out an exposure activity the same way with a child that is afraid of insects, a child that is afraid of sleeping alone, and a child that is afraid of the death of his/her parents. While it is possible to use *in vivo* exposure for some anxiety sources, imaginary exposure is the best choice in

In systematic exposure technique, first therapist and child make a list of events or situations that trigger anxiety. However, it is quite important to arrange a hierarchical order between events on the list starting from the one that creates least anxiety and ending with the one that creates most anxiety [20]. For this purpose, it will be useful to work carefully on the hierarchy, and ask for the help of parents in this process. Then, child starts to face the events on the list one by one. Mostly, the child is exposed to an imaginary situation during the session under the guidance and control of therapist before facing with it in real life. Therefore, he/she will have rehearsed the challenges that might be experienced in real life, and how he/she will cope with them in a safe environment [73, 76]. For instance, a child with social phobia might be asked to make a presentation in front of the therapist before making a presentation in the class. Thus, child starts the technique with a task that is similar to the situation where he/she will experience anxiety intensely but creates less trouble. In another instance, the child might be afraid of sleeping alone and might state in the session that he/she is frightened by the tree branches seen from the window across his/her bed during the imaginary exposure. Taking precautions about this might enable the child Social withdrawal is observed in most of the depressive and anxious children (especially, social phobia and generalized anxiety disorder) [97]. For instance, a child with social phobia might feel intense anxiety to communicate with others, and not know how to start communication either. Similarly, a depressive child might feel withdrawn due to maladaptive cognition and self-talks, and miss the social support and reinforcers that he/she might receive from the environment due to lack of social skills.

In social skills training, verbal and motor behaviors that are necessary to improve the suitable communication ways in interpersonal relationships are taught. Before starting the training, it is important to identify the lacking verbal or motor behaviors well, and establish co-operation between the child and family in the meantime. If the child has performance anxiety, main factors preventing the performance must be identified, and additional techniques must be included in the social skills training, if necessary. Social skills training is applied in children generally through techniques such as modeling, role-playing and homework. While applying these techniques, therapist must be quite active, and awareness of the child must be increased by constantly providing feedback [85].

Main focus topics of social skills training in children are weak peer relationships and conflicting parent relationships. For this reason, apart from modeling of therapist and performance of role-playing activities, exemplary behavior videos concerning the topic might be watched or peer observations might be made. After modeling activities, the practice must be criticized together with the child, and key dialogs or behaviors associated with positive results must be emphasized.

**Author details**

**References**

Emine Sevinç Sevi Tok

s10802-005-1829-8

2001. 100-121 p

10.1111/1475-3588.00019

1469-7610.2006.01682.x

00004583-199611000-00011

Address all correspondence to: eminesevinc.tok@ikc.edu.tr

Department of Psychology, Izmir Katip Çelebi University, Izmir, Turkey

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