Virtual reality is a promising tool for improving efficacy of exposure therapy for childhood anxiety disorders (CADs), particularly for exposures that are challenging to orchestrate in vivo. The present study compared virtual reality exposure (VRE) to verbal imaginal exposure (IE) on anxiety elicited, homework completion, and preparation for subsequent exposures. Forty-five youth with CADs completed both types of exposure in session (order randomly assigned), practiced one form of exposure as homework (randomly assigned), and returned a week later to repeat both exposures (in randomized order), provide user feedback, and complete a related in vivo exposure. Both VRE and IE elicited moderate anxiety that decreased to mild during the exposure and were associated with lower initial anxiety ratings in subsequent exposures. These patterns did not differ across exposure type. The two techniques did not differ on homework completion. VRE was associated with greater simulator (motion) sickness symptoms. Participants rated VRE as more realistic than IE and noted pros and cons for both approaches. The present study supported use of VRE and IE in treatment of CADs without demonstrating superiority of either technique in effectiveness or homework completion.