The Art of Exposure: Putting Science Into Practice

Is repeated mistake-making an effective treatment strategy for perfectionism? Findings from a randomized controlled trial

BACKGROUND AND OBJECTIVES

Perfectionism has been linked to self-criticism, procrastination, and psychological disorders. In a previous study, an exposure-based treatment for perfectionism (ETP), which included exposures targeted at concern over mistakes, showed positive outcomes when compared to waitlist. The aim of this study was to further investigate ETP by comparing it to a stress-management condition and assessing durability of treatment effects by conducting a one-month follow-up assessment.

METHODS

Eighty-five individuals with elevated perfectionism were randomly assigned to receive ETP (n = 43) or a stress management treatment (n = 42). ETP involved repeatedly practicing mistake-making by completing computerized tasks engineered to cause individuals to make mistakes. The stress management condition included listening to videos and answering questions about healthy habits, such as diet, exercise, and sleep, as well as viewing calming videos. Participants completed eight treatment sessions as well as baseline, post-test, and one month follow-up self-report questionnaires.

RESULTS

Contrary to predictions, compared to ETP, stress management led to significantly lower overall perfectionism, depression, generalized anxiety, and social anxiety at post and significantly lower depression, generalized anxiety, and social anxiety at follow-up. Further, individuals who completed ETP did not habituate to the exposure tasks, but distress increased from the first to the last treatment session.

LIMITATIONS

The duration of treatment was relatively brief.

CONCLUSIONS

This study highlights the importance of using active psychological control conditions in treatment outcome studies and the need to test various components of treatments for perfectionism to observe what may be effective or even potentially iatrogenic.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Values- versus monetary reward-enhanced exposure therapy for the treatment of social anxiety in emerging adulthood

Exposure therapy represents the gold-standard treatment for social anxiety, yet evidence indicates the need for improvement. One promising avenue involves linking exposures to a motivator. The current study examined the impact of intrinsically-rewarding, personal values-enhanced versus extrinsically-rewarding, monetary-enhanced exposure on short-term social anxiety fear and avoidance outcomes, and evaluated impacted initial treatment motivation and exposure generalization.

METHODS

Sixty emerging adults ages 17-26 with significantly elevated social and public speaking anxiety were randomized to receive values-enhanced exposure, monetary reward-enhanced exposure, or exposure alone. They completed a laboratory session with a brief intervention and speech exposure, one-week follow-up with novel exposure, and online follow-up two weeks later. Subjective and behavioral anxiety measures were collected.

RESULTS

Linking exposures to values decreased self-reported anxiety following the speech exposure retest, which generalized to anticipatory anxiety prior to a novel speech task. Linking exposures to money temporarily increased speech length, but this difference did not remain during the novel task. Conditions showed similar improvements on other outcomes.

CONCLUSION

Extrinsic motivators can temporarily motivate exposure engagement, whereas a brief values intervention can enhance exposure learning and decrease subjective anxiety across feared situations compared to monetary enhancement. If replicated, this has pragmatic implications for exposure framing within social anxiety treatment.

Parent-led cognitive behaviour therapy for child anxiety problems: overcoming challenges to increase access to effective treatment

BACKGROUND

Anxiety problems have a particularly early age of onset and are common among children. As we celebrate the anniversary of the BABCP, it is important to recognise the huge contribution that cognitive behavioural therapy (CBT) has made to the treatment of anxiety problems in children. CBT remains the only psychological intervention for child anxiety problems with a robust evidence base, but despite this, very few children with anxiety problems access CBT. Creative solutions are urgently needed to ensure that effective treatments can be delivered at scale. Here we focus on parent-led CBT as this offers a potential solution that is brief and can be delivered by clinicians without highly specialised training. Over the last decade there has been a substantial increase in randomised controlled trials evaluating this approach with consistent evidence of effectiveness. Nonetheless clinicians, and parents, often have concerns about trying the approach and can face challenges in its delivery.

METHOD

We draw on empirical evidence and our clinical experience to address some of these common concerns and challenges, with particular emphasis on the key principles of empowering parents and working with them to provide opportunities for new learning for their children.

CONCLUSIONS

We conclude by highlighting some important directions for future research and practice, including further evaluation of who does and does not currently benefit from the approach, determining how it should be adapted to optimise outcomes among groups that may not currently get maximum benefits and across cultures, and capitalising on recent technological developments to increase engagement and widen access.

Preliminary Implementation Outcomes of a Free Online Toolkit to Support Exposure Therapy Implementation for Youth

Background

Exposure therapy ("exposure") for youth anxiety is highly underutilized in clinical practice. Asynchronous, online implementation strategies such as online toolkits hold promise as pragmatic approaches for extending the sustainability of evidence-based interventions, but their long-term usage, perceived utility, and impact are rarely studied.

Objective

This study presents three-year preliminary implementation outcomes for a free, online toolkit to support exposure therapy use with youth: the Resource for Exposure for Anxiety Disordered Youth (READY; www.bravepracticeforkids.com). Implementation outcomes of interest included READY usage statistics, adoption, perceived utility, and clinician exposure use.

Methods

Web analytics characterized usage patterns. A survey of READY users (N = 49; M age = 34.2, 82.9% female, 71% White) assessed adoption, perceived utility, clinician exposure use, and persistent barriers to exposure use.

Results

In its first three years, READY had 13,543 page views across 1,731 unique users; 442 (25.6%) registered as a site user to access specialized content. Survey data suggested variability in usage and perceived utility across toolkit components. Qualitative analyses highlighted persistent exposure barriers that pointed to potential READY refinements.

Conculsions

Overall, READY has been accessed by hundreds of clinicians, but its impact was limited by low return to the site. This study highlights strengths and limitations of standalone online implementation supports and identifies additional steps needed to optimally support clinicians to deliver exposure to youth in need.

Adapting CBT for youth anxiety: Flexibility, within fidelity, in different settings

Anxiety disorders are common in youth, associated with impairments in daily functioning, and often persist into adulthood when untreated. Cognitive behavioral therapy (CBT) for youth anxiety is a well-established intervention and has been modified to fit several treatment settings. Despite decades of results supporting the efficacy of CBT, there is a large gap in access to this treatment and a need to consider how it can best be administered flexibly to increase uptake and personalization. We first discuss the core components of treatment for CBT through the lens of the Coping Cat treatment. Next, we review the empirical findings regarding adjustments made for CBT for youth anxiety delivered (a) in schools, (b) in community settings, (c) through telehealth, (d) through online computer programs, and (e) by caregivers at home. In each setting, we provide specific suggestions for how to implement CBT with flexibility while maintaining fidelity.

School-based supports and accommodations among anxious youth in treatment

Within pediatric anxiety, accommodation describes ways caregivers modify their behavior in an effort to alleviate distress shown by anxious youth. In schools, accommodation refers to school-based supports (SBS) placed to increase academic success for students with disabilities. The present study, using school documents provided at treatment, examined the types of SBS provided to youth (N = 76; ages 7-17; mean age 11.07; 47.4 % female) diagnosed with an anxiety disorder. SBS were rated by a panel of youth anxiety experts on the degree to which each SBS promoted (a) approach or (b) avoidance. School documents were coded for the presence of SBS and each SBS received a (a) total approach and (b) total avoidance score. Analyses revealed (a) approach and (b) avoidance promoting SBS were differentially associated with diagnostic status: youth with social anxiety disorder were more likely to be recommended SBS promoting avoidance and youth with a specific phobia were more likely to be recommended SBS promoting approach. Overall, the present study characterizes types of SBS being received by anxious youth and finds that SBS recommended to anxious youth vary in type and quality. Discussion considers the need for observations in schools to further address the merits/demerits of anxiety-related SBS.

Pediatrician-friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal

Pediatric anxiety disorders are common and often debilitating conditions. Cognitive is a psychosocial intervention that represents a potentially powerful antidote to these disorders. This article reviews data from treatment outcome studies, meta-analyses, and systematic reviews as well as from moderation/mediational investigations. The literature supports the efficacy, effectiveness, and durability of positive treatment outcomes for pediatric anxiety disorders. Recommendations for clinical applications are suggested.

"Less stress": a pilot study on a cognitive behavioral treatment program for anxiety in children with autism spectrum disorders

Background:

Comorbid anxiety disorders are prevalent in children with autism spectrum disorders (ASD), but only a minority receives adequate treatment for anxiety. Cognitive behavioral therapy (CBT) has been shown to be effective in treating anxiety disorders. The objectives of the present pilot study were to test the feasibility of the CBT program “Less stress” for comorbid anxiety disorders in children with ASD and explore whether an improvement in diagnostic outcomes for anxiety disorders and symptoms of anxiety was found after treatment.

Methods:

Participants were ten children diagnosed with ASD and anxiety disorders (eight boys, mean age = 9.5 years, range 8 - 12 years). The “Less Stress” program includes three months of weekly treatment sessions followed by three monthly booster sessions. Five therapists participated. A standardized semi-structured diagnostic interview with the mothers was used to assess comorbid disorders. Child anxiety symptoms were measured with the Revised Child Anxiety and Depression Scale (RCADS).

Results:

The therapists found the manual easy to use but adaptations were necessary, particularly shorter sessions due to frequent (n = 7) comorbid Attention-Deficit/Hyperactivity Disorder. The participants found the program useful and the parents noted that they had learned methods they could continue using after the end of the program.

Eight of ten children completed the treatment. Seven of the eight completers benefited from the program. Five of those seven children were free from all anxiety disorders, while two had fewer anxiety disorders. On a group level, a significant mean reduction of anxiety symptoms (RCADS) was found after treatment.

Conclusion:

The therapists found the “Less stress” program to be a feasible intervention in a sample of children with ASD and comorbid anxiety. The significant reduction of anxiety after treatment is promising, but a replication in a larger and more rigorous study is needed to investigate the effectiveness of the intervention.

The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders

This study examined the relationship between caregivers' and youths' treatment expectations and characteristics of exposure tasks (quantity, mastery, compliance) in cognitive-behavioral therapy (CBT) for childhood anxiety. Additionally, compliance with exposure tasks was tested as a mediator of the relationship between treatment expectations and symptom improvement. Data were from youth (N = 279; 7-17 years old) enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS) and randomized to cognitive-behavioral therapy (CBT) or the combination of CBT and sertraline for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. Caregivers and youth independently reported treatment expectations prior to randomization, anxiety was assessed pre- and post-treatment by independent evaluators blind to treatment condition, and exposure characteristics were recorded by the cognitive-behavioral therapists following each session. For both caregivers and youths, more positive expectations that anxiety would improve with treatment were associated with greater compliance with exposure tasks, and compliance mediated the relationship between treatment expectations and change in anxiety symptoms following treatment. Additionally, more positive parent treatment expectations were related to a greater number and percentage of sessions with exposure. More positive youth treatment expectations were associated with greater mastery during sessions focused on exposure. Findings underscore the importance of addressing parents' and youths' treatment expectations at the outset of therapy to facilitate engagement in exposure and maximize therapeutic gains.

The use of acceptance and commitment therapy (ACT) in addressing family accommodation (FA) for child anxiety

Many parents of children with anxiety tend to engage in varying levels of family accommodation (FA) in order to alleviate anxiety symptoms. This can exacerbate anxiety symptoms and have adverse effects for psychological treatments. A small number of general and specific interventions have been developed for FA but treatment research is at a nascent stage. Acceptance and commitment therapy (ACT) may be an effective treatment for FA. This article reviews the potential advantages and uses of ACT and how ACT’s six core processes can help target particular features of FA. The theoretical support for ACT is reviewed relevant to FA. The article concludes by conjecturing how ACT may be a useful and adaptive treatment in targeting FA.

Key learning aims

(1)

Optimising Exposure for Children and Adolescents with Anxiety, OCD and PTSD: A Systematic Review

Cognitive behavioural therapy is an effective treatment for anxiety disorders in children and young people; however, many do not benefit. Behavioural exposure appears to be the critical ingredient in the treatment of anxiety disorders. Research with adults has identified innovative strategies to optimise exposure-based treatments, yet it is not clear how to optimise the effects of exposure for children and young people. This review was a preliminary exploration of the association between potential optimisation strategies and treatment procedures and outcomes for the treatment of child anxiety symptoms/disorders. We searched Psych-Info and Medline databases using a systematic search strategy and identified 29 articles. We found preliminary evidence that some specific strategies may enhance the effects of exposure, such as dropping safety behaviours, parents and therapists discouraging avoidance, and the use of homework. However, not one significant finding was replicated by another study for the same timepoint using the same methodology. To a large degree, this lack of replication reflects a limited number of studies combined with a lack of consistency across studies around conceptualisations, methodological approaches, and outcome measures making it difficult to make meaningful comparisons between studies and draw firm conclusions. Examination is needed of a wide range of theoretically-driven potential optimisation strategies using methodologically robust, preclinical studies with children and young people. Furthermore, the methods used in future research must enable comparisons across studies and explore developmental differences in the effects of particular optimisation strategies.

Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19

The novel coronavirus (COVID-19) pandemic has caused widespread disruption to our traditional way of life and mental health therapy has not been spared. A combination of increased anxiety, diminished social opportunities, and the shift to telehealth service provision presents particular challenges for the treatment of social anxiety in youth, which relies heavily on exposures to social situations with peers, adults, or other feared social stimuli. The objective of this commentary is to provide guidance to clinicians working with youth with social anxiety on how to maintain ethical, evidence-informed provision of exposure therapy in light of these unusual circumstances. We first present an overview of how COVID-19 may uniquely impact youth with social anxiety and highlight the importance of continuing to provide exposure-based treatments during this time. We then discuss guiding principles for delivering exposure therapy during COVID-19. We focus on providing practical examples of how common social anxiety exposures can be adapted and delivered successfully through telehealth while abiding by COVID-19 social distancing guidelines. Finally, we discuss key recommendations to assist clinicians in moving treatment forward while considering changing safety guidelines pertaining to COVID-19.

Separation Anxiety Symptom Profiles and Parental Accommodation Across Pediatric Anxiety Disorders

Parental accommodation refers to ways in which caregivers modify their behavior to decrease child distress in the short-term. Accommodation is prevalent among anxious youth and related to decreased treatment and functional outcomes. Although separation anxiety disorder (SAD) is associated with increased accommodation, SAD is not a predictor of treatment response, suggesting that a diagnosis of SAD alone may not be enough to clarify the relationship between accommodation and separation anxiety symptoms within a clinical context. Participants were youth with a primary anxiety disorder (N = 186; aged 7-17) enrolled in an outpatient anxiety clinic. Latent class analysis was used to extract profiles from parent-reported SAD symptoms using the Anxiety Disorders Interview Schedule for DSM-IV/5. Profiles were compared on pre-treatment accommodation. Low, moderate, and interfering SAD classes emerged. Interfering SAD was associated with high accommodation. Results help to clarify the association between SAD and accommodation and has implications for personalized intervention.

Rapid Return for School Refusal: A School-Based Approach Applied With Japanese Adolescents

Cognitive behavioral therapy (CBT) is often effective in the treatment of school refusal (SR). Its usefulness is limited, however, if youth displaying SR also refuse to attend treatment sessions. In these cases parents and school staff may consider using school-based interventions that do not rely on face-to-face assessment and treatment with the young person. The current study examined the effectiveness of a school-based intervention applied in Japan to achieve rapid return to school among adolescents displaying SR. Between 2009 and 2015, the parents of 62 adolescents displaying SR were invited to implement a school-based rapid return approach. Thirty-nine parents agreed to implement the approach and 23 decided to wait until their child spontaneously attended school. Of the 39 cases in which the approach was implemented, 28 adolescents (72%) resumed attendance at their original school, 2 (5%) transferred to another school, and 9 (23%) did not resume attendance. In contrast, all 23 non-intervention cases continued to refuse to attend school for 3 months or longer, and none of these adolescents returned to regular school attendance within 9 months. This study tentatively suggests that the rapid return approach may be an effective form of intervention for adolescents displaying SR and simultaneously refusing to attend individual therapy. Because this approach is ethically complex, involving forced school attendance in adolescence, it should only be employed under specific circumstances. These circumstances are discussed.

Practitioner Review: School refusal: developments in conceptualisation and treatment since 2000

BACKGROUND

A generation has passed since the literature on the conceptualisation, assessment and treatment of school refusal was reviewed in this journal (Elliott, ). In the light of considerable gaps in the literature, identified at that time, and growing international interest, the current paper sought to identify progress subsequently made this century.

METHODS

We open with discussion of continuing conceptual uncertainty as to whether school refusal should incorporate both truancy and absenteeism marked by anxiety and distress. We then consider progress in treatment, and conclude by examining prognosis and subsequent adult functioning. In selecting intervention studies for review, our primary focus has been upon RCTS, systematic reviews and meta-analyses.

RESULTS

The literature review indicates that, since the turn of the century, there has been little substantial advance in knowledge that can guide practitioners. Many of the issues raised in the 1999 paper, in particular, conceptual confusion over this heterogeneous condition, a dearth of rigorous RCT designs, limited knowledge of underlying mechanisms and uncertainty as to the long-term effects of specific forms of intervention, are little clearer than before.

CONCLUSIONS

While several sound publications are available to guide intervention for school refusal, there is a continuing need for rigorous studies that can provide evidence to support individualised and tailored responses to an incapacitating problem with many causes and manifestations. While a multisystemic response to intervention approach is considered attractive, the practicalities of operating this across disparate professional borders are likely to present a long-term challenge.

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial

Background

Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo).

Objective

The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment.

Methods

We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification.

Results

Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06).

Conclusions

The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment.

Therapist-Reported Features of Exposure Tasks That Predict Differential Treatment Outcomes for Youth With Anxiety

OBJECTIVE

Exposure tasks are recognized widely as a key component of cognitive-behavioral therapy (CBT) for child and adolescent anxiety. However, little research has examined specific exposure characteristics that predict outcomes for youth with anxiety and that may guide its application in therapy.

METHOD

This study draws on a sample of 279 children and adolescents (48.4% male; 79.6% white) with a principal anxiety disorder who received 14 sessions of CBT, either alone or in combination with medication, through the Child/adolescent Anxiety Multimodal treatment Study (CAMS). The present study examines therapist-reported quantity, difficulty level, compliance, and mastery of exposure tasks as they related to CBT response (i.e., Clinical Global Impressions-Improvement ratings). Secondary treatment outcomes included reduction in anxiety symptom severity on the Pediatric Anxiety Rating Scale, global impairment measured via the Children's Global Assessment Scale, and parent-report of anxiety-specific functional impairment on the Child Anxiety Impairment Scale.

RESULTS

Regression analyses indicated a dose-response relationship between therapist-reported quantity of exposure and independent evaluations of treatment outcome, with more time devoted to exposure linked to better outcomes. Similarly, greater time spent on more difficult (rather than mild or moderate) exposure tasks predicted better outcomes, as did therapist ratings of child compliance and mastery.

CONCLUSION

The present findings highlight the importance of challenging children and adolescents with difficult exposure tasks and of collaborating to ensure compliance and mastery.

Feasibility and acceptability of a toolkit to facilitate clinician use of exposure therapy for youth

Exposure therapy is a key element of cognitive-behavioral therapy for youth with anxiety. However, few clinicians outside of specialty anxiety clinics routinely use exposures with anxious youth. This study reports on the acceptability and feasibility of a clinician support toolkit for exposures with anxious youth in community settings. The toolkit was developed through an extensive literature review of exposure science and cited barriers to exposure therapy, with input from multiple experts in pediatric anxiety (n = 10). Acceptability and feasibility data was gathered via survey from 70 community clinicians attending a training on exposure therapy for youth. Qualitative data was collected from a subset of participants who used the toolkit with youth on their caseload for approximately one month. Survey data suggested that the toolkit was viewed highly favorably. Qualitative interviews indicated that the toolkit was viewed as a feasible therapeutic tool that positively impacted clinician motivation to use exposure. Primary challenges related to exposure use more generally, and included client and service setting barriers. Results suggested initial toolkit acceptability and feasibility. Future work to refine the toolkit and test its efficacy as an implementation strategy to increase clinician use of exposure therapy is warranted. Next steps include development of additional content in partnership with key stakeholders, and testing the toolkit's impact on increasing clinician use of exposure therapy.

Using Research-Informed Pedagogical Practices to Maximize Learning in Youth Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) for youth is an evidence-based treatment that typically starts with some form of psychoeducation, during which the patient is taught in a didactic manner about their presenting problems and strategies to ameliorate their symptoms. The learning process continues over the course of treatment as patients consolidate and attempt to utilize their aqcuired knowledge in their daily life. Manuals provide helpful structure and strategies to facilitate this learning process (e.g., using metaphors, personalized coping cards); however, there is variability across patients in terms of what presented content they will be able to access and understand, how they can most effectively transfer what they learn into their everyday life, and why they will become engaged in this learning process. The purpose of this paper is to connect CBT and pedagogy by outlining the research-informed pedagogical framework known as Universal Design for Learning (UDL) as it relates to the teaching and learning that takes place in CBT. First, we describe UDL as a lens through which clinicians can conceptualize evidence-based pedagogical principles that undergird common CBT teaching practices. Second, we recommend that clinicians use UDL as a guiding framework when they are faced with barriers to learning due to the variability that exists in how patients engage in, access and understand, and utilize the material. We posit that UDL can help clinicians ensure that more patients are able to successfully access and benefit from CBT.

Adapting Cognitive Behavioral Therapy for Anxious Children and Adolescents

This article discusses considerations for adapting cognitive behavioral therapy (CBT) techniques and processes with anxious children and adolescents. To successfully deliver CBT with this population, the therapist must take into consideration the child's developmental level and other contextual factors that may affect treatment outcome. Suggested adaptions to CBT include the use of rewards, technology, and interactive activities to increase child motivation and engagement. Moreover, dependent on the child's or adolescent's cognitive capacity, cognitive techniques will need to be simplified and concrete examples provided to increase children's understanding. It may be beneficial to have parents and/or schools involved in children's treatment to assist them to implement CBT strategies outside of the therapy setting. A case example is presented to illustrate the implementation of CBT with a child.

ACCOMMODATION AND TREATMENT OF ANXIOUS YOUTH

BACKGROUND

Parental accommodation refers to the ways in which a parent modifies their behavior to avoid or reduce the distress their child experiences. Parents of youth with anxiety disorders have been found to accommodate their child's anxiety in a variety of ways that contribute to the maintenance of the disorder. The current study evaluated the relationship between parental accommodation and the outcome of treatment for youth with anxiety.

METHODS

Sixty-two youth (age 6-17) and their parents were evaluated for youth anxiety and parental accommodation before and after treatment. All youth received individual cognitive behavioral therapy (CBT).

RESULTS

Parental accommodation was significantly reduced from before to after treatment. Reduction in parent-rated accommodation was significantly associated with the severity of youth's posttreatment anxiety, even when controlling for pretreatment youth anxiety. Level of pretreatment accommodation was significantly associated with treatment response.

CONCLUSIONS

Findings indicate that parental accommodation is significantly reduced after individual youth CBT, and suggest that accommodation may be an important treatment focus. Clinical implications and future directions are discussed.

In Pursuit of Generalization: An Updated Review

Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osnes's original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors, are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.

Testing the Habituation-Based Model of Exposures for Child and Adolescent Anxiety

Exposure has been identified as key to effective treatment of youth anxiety. However, the precise theoretical mechanisms of exposure are a matter of debate. Emotional processing theory emphasizes the need for fear activation during exposure and its habituation both within and across exposures. Despite the popularity of the theory to explain exposure, it has not been tested with anxious youth. To determine whether emotional processing theory parameters predict anxiety severity, coping abilities, and global functioning after cognitive-behavioral treatment. The present study examined 72 youth (M_age = 10.50 years; 45% female; 87.5% non-Hispanic Caucasian) diagnosed with an anxiety disorder and who received family or individual CBT. Three exposure habituation variables-initial fear activation (peak anxiety), within-session habituation, and between-session habituation-were assessed using Subjective Units of Distress and examined as predictors of outcome at posttreatment and at 1-year follow-up. Outcomes were measured using the Coping Questionnaire, Multidimensional Anxiety Scale for Children, Revised Children's Manifest Anxiety Scale, Children's Global Assessment Scale, and clinician severity ratings on the Anxiety Disorder Interview Schedule. Emotional processing theory variables did not predict any anxiety outcomes at posttreatment or follow-up with one exception: Initial fear activation predicted less anxiety at follow-up among youth without GAD. In addition, within- and between-session habituation were not associated with one another. Between-session habituation was not associated with initial fear activation. These findings suggest a limited role of habituation within cognitive-behavioral therapy for anxiety in youth. An alternative to emotional processing theory, inhibitory learning theory, is discussed.

Optimising Extinction of Conditioned Disgust

Maladaptive disgust responses are tenacious and resistant to exposure-based interventions. In a similar vein, laboratory studies have shown that conditioned disgust is relatively insensitive to Conditioned Stimulus (CS)-only extinction procedures. The relatively strong resistance to extinction might be explained by disgust’s adaptive function to motivate avoidance from contamination threats (pathogens) that cannot be readily detected and are invisible to the naked eye. Therefore, the mere visual presentation of unreinforced disgust eliciting stimuli might not be sufficient to correct a previously acquired threat value of the CS+. Following this, the current study tested whether the efficacy of CS-only exposure can be improved by providing additional safety information about the CS+. For the CSs we included two neutral items a pea soup and a sausage roll, whereas for the Unconditioned Stimulus (US) we used one video clip of a woman vomiting and a neutral one about glass blowing. The additional safety information was conveyed by allowing actual contact with the CS+ or by observing an actress eating the food items representing the CS+. When additional safety information was provided via allowing direct contact with the CS+, there was a relatively strong post-extinction increase in participants’ willingness-to-eat the CS+. This beneficial effect was still evident at one-week follow up. Also self-reported disgust was lower at one-week follow up when additional safety information was provided. The current findings help explain why disgust is relatively insensitive to CS-only extinction procedures, and provide helpful starting points to improve interventions that are aimed to reduce distress in disgust-related psychopathology.

Socratic Questions With Children: Recommendations and Cautionary Tales

This clinically focused article offers cognitive behavior therapists recommendations and cautionary tales for using the Socratic method when working with children. The importance of the therapeutic relationship in combination with developmental considerations is discussed. The use of Socratic method in various cognitive behavioral modules is illustrated by means of case examples. Dialogues provide examples of how the cognitive specificity hypothesis and downward arrow technique can be used to support young clients in eliciting negative automatic thoughts. The importance of pacing, the mixing of closed and open-ended questions, and behavioral experiments to aid cognitive restructuring are also highlighted through extracts from clinical conversations. Finally, the article emphasizes that the purpose of the Socratic method is to broaden thinking and to access new knowledge rather than just giving young clients new thoughts and problem solving strategies.