Published by Unseen Progress, an independent publisher of caregiver research. Last reviewed 2026-05-10. Part of the child anxiety research overview.
Short answer. Yes — and that is usually how the treatment works. Exposure and response prevention deliberately raises visible anxiety in the early weeks because habituation requires sustained, un-escaped contact with the feared stimulus. The clinical literature (Foa & Kozak, 1986; POTS Team, 2004; Walkup et al., CAMS, 2008) treats early-treatment distress increases as an expected feature of an active course, not as a sign of harm. The signals that distinguish therapeutic distress from genuine regression are specific and observable, and they are not the ones most parents are weighing in the moment.
Foa and Kozak's emotional processing theory (1986), which underpins almost every modern manual of exposure-based treatment, describes the mechanism plainly: a fear network is modified by repeated, prolonged contact with a stimulus that does not in fact produce the feared outcome. For the network to update, the child has to feel the fear. A child who avoids, distracts, or rituals their way through an exposure receives no learning signal — the fear network's prediction was never tested. The visible distress is the test. Without it, no extinction.
Translated into a parent's living room: a child who has spent two years avoiding the school drop-off does not experience meaningful relief in week one of treatment. They experience the school drop-off, possibly for the first time in months, and they feel the fear they have been avoiding. The POTS trial (POTS Team, 2004) documents exactly this pattern in paediatric OCD — distress ratings during exposure sessions are highest in weeks 2–6, then taper as habituation accrues, while between-session avoidance falls more slowly across the same window. Parents reading week-to-week severity see only the first curve.
Lebowitz and colleagues (2013, 2020) add a second mechanism. As parental accommodation is reduced — the bedtime check, the answered reassurance question, the modified routine — the child loses access to the relief valves that previously contained the symptom. The disorder becomes more visible to the parent precisely because it is no longer being absorbed by the family system. More visible and more severe are easy to confuse and not the same thing.
When parents say "my child is more anxious since we started ERP," they usually mean one of three observable changes:
1. In-session distress is high and loud. Tears, panic, refusal during the exposure itself. 2. Between-session anxiety has risen at home in the first 2–4 weeks. Bedtime is harder, mornings are harder, the requests for reassurance are more frequent. 3. The child is angry at the parent and the therapist. Reduction in accommodation feels, to the child, like withdrawal of love. They protest accordingly.
Each of these is consistent with treatment working. Each can also occur in genuine regression. The literature gives clear separators.
A well-running exposure shows the SUDS curve dropping across a single session and across repeated exposures to the same target (Foa & Kozak, 1986). The child arrives at SUDS 8, sits in the exposure, and leaves at SUDS 5. Two sessions later, the same exposure starts at 6 and ends at 3. Distress within and across exposures should be falling, not rising. If it is flat or climbing across many sessions on the same target, that is a clinical conversation — usually a hierarchy adjustment, not a treatment failure.
Between-session avoidance is the slower-moving curve and is the one parents should weight. Across 8–12 weeks, the count of avoided situations should drop, even while in-session distress is high (POTS Team, 2004). A bedtime ritual taking 22 minutes instead of 40, three school drop-offs without resistance instead of zero, one independent exposure attempt at home — these are the markers.
A child whose existing fear is louder is, almost always, in active treatment. A child developing genuinely new fears, new compulsions, new safety behaviours, or new diagnostic-level symptoms (depression, eating restriction, self-harm) is in a different conversation. The AACAP Practice Parameter explicitly distinguishes these: louder existing symptoms are within the expected envelope; new symptom domains require reassessment.
Trained ERP clinicians have explicit response criteria and predefined points of escalation. If your therapist is calmly saying "this is what I expect at week three," that is meaningful — their session view, calibrated against the trial literature, places the current presentation in the expected range. If the therapist is themselves uncertain or proposing changes to the hierarchy, that is the signal worth weighting.
Across r/Anxiety, r/OCD, and r/Parenting, this paradox shows up in nearly identical phrasing:
The shape of the question is itself the symptom: the parent is being asked, by their own nervous system, to interpret the loudness of the moment as a treatment verdict. The literature is clear that the loudness of the moment is not the verdict.
1. Distinguish therapeutic distress (during or immediately after exposure) from background anxiety (across the whole week). Track both separately. 2. Commit to the plan for a minimum of 8–12 weeks before renegotiating it. POTS-style treatment shows its first meaningful gains between sessions 4 and 8 (POTS Team, 2004). 3. If new symptom domains appear — not louder old ones — bring that explicitly to the therapist as a discrete observation. 4. Audit accommodation reduction honestly. Most parents underestimate how much they accommodate; some of the apparent worsening is symptom that was previously absorbed by the family becoming visible.
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