Cognitive and Behavioral Interventions

Hierarchy development is an integral component of graded exposure therapy for anxiety disorders. A hierarchy, often referred to as a “fear ladder” (e.g., Kendall & Hedtke, 2006), is a list of anxiety-provoking situations, or stimuli that a child avoids, organized in order of increasing difficulty. Hierarchies can take numerous forms, such as a written list, drawing of a ladder (e.g., Kendall & Hedtke, 2006), picture of a pyramid, or a map of different sized “islands” based on the level of anxiety provoked by each situation (e.g., March & Mulle, 1998). The hierarchy is developed in the beginning sessions of therapy and is used as an assessment tool to aid in case conceptualization and treatment planning. Hierarchies are also guides for determining graduated exposure or desensitization exercises to conduct in therapy.