Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training

OBJECTIVE

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies.

METHODS

Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions.

RESULTS

Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001).

CONCLUSION

The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Translation of a family-based behavioral intervention for adolescent obesity using the RE-AIM framework and common steps from adaptation frameworks

Interventions for adolescent weight management that are ready to use in clinical settings are needed to address the obesity epidemic and improve the health and wellbeing of affected adolescents. This report describes the systematic process our team followed to adapt an evidence-based intervention (EBI) for adolescent weight management from its randomized control trial protocol to a package for delivery in a group-based telehealth format within a medical center. The EBI adaptation was clinician initiated, prompted by identified practice needs, and involved collaboration of the clinical team with the EBI developer. The process was guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and followed key steps for adapting EBIs to new contexts. RE-AIM-aligned adaptations included telehealth delivery and broader inclusion criteria, separate clinical and research evaluation batteries, adaptations to fit the clinical practice, practical fidelity checklists to guide and record session delivery, and continuous quality improvement processes aimed to facilitate program longevity and family engagement. The process culminated in a package of adapted intervention materials deemed by stakeholders as appropriate to the practice and congruent with the EBI model. This report provides a much-needed practical demonstration of the translation of an EBI for adolescent weight management from research protocol to group telehealth delivery in a medical center. Key lessons include the value of clinician-researcher collaboration, the breadth of resources needed to adapt EBIs for real-world delivery, and the importance of considering delivery context in implementation and evaluation decisions, including defining inclusion criteria, staffing, and outcomes assessments.

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8-18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure-however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists' use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.

Physical Symptoms, Distress, and Functional Disability in Youth With Chronic Orthostatic Intolerance

OBJECTIVE

Youth with chronic orthostatic intolerance (OI) can experience significant physical, social, and academic functional debilitation. Previous studies have indicated associations among symptom severity, psychosocial factors, and functional disability. However, empirically tested models explaining how different medical and psychosocial factors may contribute to functional disability are lacking. The current cross-sectional study aimed to evaluate mediation, moderation, and additive models of the effect of physical symptoms and psychological distress on functional disability.

METHODS

One hundred and sixty-five youth (13-22 years old) undergoing medical evaluation of chronic OI symptoms completed measures of autonomic dysfunction symptom severity, depressive and anxiety symptoms, and functional disability. Models were evaluated using tests of indirect effects and linear and logistic regression analyses.

RESULTS

Results supported the mediation and additive effects models for depressive symptoms. Mediation, moderation, and additive models for hypothesized effects of anxiety symptoms were not supported.

CONCLUSIONS

Results provide preliminary support for models in which OI symptoms affect functional debility via their effects on mood and in which depressive symptoms have unique and additive effects on functioning. Findings lay the foundation for longitudinal and experimental evaluation of biopsychosocial models of functional disability in youth with chronic OI and related conditions. Implications include the importance of a biopsychosocial conceptualization of OI symptoms and debility as a complex interplay of factors rather than as a purely physiological or psychological process.

Quantifying Session Content in the Delivery of Parent Coached Exposure Therapy

Despite exposure therapy having been identified as the active ingredient in the treatment of childhood anxiety disorders (CADs), available protocols deliver a variety of anxiety management strategies (AMS) in addition to exposure. To increase the effectiveness and efficiency of treatment, Parent Coached Exposure Therapy (PCET): 1) begins exposure early (e.g., session 2 or 3) to increase session time spent on exposure, 2) does not include other AMS, and 3) involves parents at all times. The current manuscript uses audio recordings from a previous pilot study to descriptively quantify the manner in which these key components of PCET are implemented by therapists closely involved in the development of the protocol. Results indicate that implementation of PCET accurately reflected the protocol in that the majority of session time was devoted to exposure activities (.60, s.d. = 0.2), AMS were effectively excluded from treatment (.01, s.d. = .03), and that parents and youth attended almost the entirety of session time together (.98, s.d. = 0.1). These findings suggest that PCET differs meaningfully from traditional CBT for CADs and provide preliminary guidelines for how much time per session to dedicate to in-session exposure work while delivering PCET.

Community Therapist Response to Technology-Assisted Training in Exposure Therapy for Childhood Anxiety Disorders

Despite the efficacy of exposure for childhood anxiety disorders (CADs), dissemination has been unsuccessful. The current study examined community-therapist response to a brief (90-minutes) training in technology-assisted exposure therapy for CADs. The results indicated that therapists found the training in the therapy approach and technology acceptable, despite endorsing mainly non-exposure-based practice prior to the training. Training also increased positive beliefs about exposure, t (23) = 4.32, p < .000, that persisted 6 months later, t (23) = 4.56, p < .000. In addition, the number of therapists reporting an intention to implement exposure increased substantially from baseline (41.7%) to post-training (83.3%), with many therapists (70.8%) reporting use of exposure within the 6 months following training. However, automatically recorded data indicated little use of the technology. Results suggest that a dissemination message focusing on exposure is acceptable and has the potential to increase the use of this central treatment component.

The feasibility of verbal and virtual reality exposure for youth with academic performance worry

With exposure emerging as a key ingredient in anxiety treatment for childhood anxiety disorders (CADs), expansion of exposure techniques is a promising avenue for improving treatment efficacy. The present study examined use of imaginal exposure (IE), a technique understudied in the treatment of CADs. Specifically, the study tested whether two forms of exposure to worries (verbal IE and virtual reality exposure therapy, VRET) would be effective and acceptable forms of exposure with youth. Twenty youth with fears of academic failure completed both types of worry exposure, presented in randomized order. Regardless of order of presentation, both verbal IE and VRET elicited moderate anxiety that decreased to mild over the span of the exposures. Both were found to be acceptable by youth and neither was associated with negative side effects. Youth found VRET to be slightly more interesting and novel, but noted that verbal IE was more realistic and individualized. The present study supports the use of standalone worry exposure as an effective and acceptable treatment for general worries in youth and suggests VRET could be more effective with improved realism.