Exposure Therapy for Children with Anxiety and OCD: Clinician's Guide to Integrated Treatment [1 ed.] 0128159154, 9780128159156

Table of contents :
Cover
Exposure Therapy for Children with Anxiety and OCD: Clinician’s Guide to Integrated
Treatment
Copyright
Dedication
Contents
List of contributors
Preface
References
Section I: Basics of exposure therapy for children and adolescents
1 History and theoretical underpinnings of exposure therapy*
Systematic desensitization
The habituation model
The inhibitory learning model
Common techniques
Specific techniques
Exposure therapy for children and adolescents
Conclusion
Acknowledgment
References
Further reading
2 Efficacy of exposure-based cognitive behavioral therapy for youth anxiety and obsessive-compulsive disorder
Introduction
Overview of cognitive behavioral therapy for youth anxiety disorders
Examples of key interventions for youth anxiety disorders
The Coping Cat program
Cool Kids
Delivery format considerations for anxiety disorder treatment
Remote treatment
Treatment intensity
Group or individual therapy
Impact of clinical characteristics on anxiety disorder treatment
Family factors
Social anxiety disorder
Specific phobias
Comorbid disorders
Overview of cognitive behavioral therapy for youth obsessive–compulsive disorder
Examples of key interventions for obsessive-compulsive disorder
The Pediatric OCD Treatment Study
The Pediatric OCD Treatment Study Junior
Nordic Long-Term OCD Treatment Study
Delivery format considerations for obsessive–compulsive disorder treatment
Remote treatment
Intensive treatments
Impact of clinical characteristics on obsessive–compulsive disorder treatment
Family factors
Comorbid disorders
Conclusion
References
3 Psychoeducation for exposure therapy
Psychoeducation on exposure therapy
The role of psychoeducation
Overview of psychoeducation for exposure therapy with anxious youth
Introducing exposure therapy
Providing a treatment rationale
Implementing exposure therapy (and response prevention)
Maximizing exposure therapy outcomes
Avoid distraction from/interference with processing the new conditioned stimulus—no unconditioned stimulus association
Strategies to enhance arousal and engagement during exposure therapy
Strategies to enhance the consolidation of corrective learning
Overcoming challenges encountered in psychoeducation for exposure therapy
Concluding remarks
Appendix 1
References
Further reading
4 Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy
Evidence-based assessment to build a hierarchy
Interviews and measures for the practicing clinician
Youth and parent report of symptom severity and impairment in anxiety and OCD
Translating assessment into treatment
Introducing the hierarchy
Establishing anchors
Getting creative with it
Putting your hierarchy to use
Adjustments throughout treatment
References
5 Developing and implementing successful exposure-based interventions
Basic illustrative case
Determining the presence of phobia
Key symptoms and genesis of feared situations
Identifying target stimuli
Developing the hierarchy
Setting up the subjective units of distress
Developing the hierarchy—it is a phenomenological exercise
At last, hierarchy development
Change begins with the hierarchy
Getting into the finer points
Involve all the senses
Developing and implementing exposure exercises
The first exposure exercise
Therapist behavior during exposure
Making the most of exposure
Between session exercises
Rewarding exposure
Rewarding younger children
Rewarding older children
Between-session exposure assignments
Moving up the hierarchy
Barriers to successful exposure therapy
Therapist factors
Child factors
Planning for termination
Conclusion
References
Section II: Implementing exposure by diagnosis
6 Exposure therapy for childhood selective mutism: principles, practices, and procedures
Exposure therapy for selective mutism: developmental and clinical considerations
Key elements of exposure therapy for childhood selective mutism
Assessment
Psychoeducation and real-time parent coaching
Reinforcement
Stimulus fading
Shaping
Coping strategies
Fear hierarchies and graduated exposure activities
Homework and promoting generalization in the community
What to say when someone asks why a child does not speak
Question cards and generalization practices
Generalization in schools
Challenging issues in exposure therapy for childhood selective mutism
Education accommodations
Comorbidity
Medication
Conclusion and future directions
References
Further reading
7 Exposure therapy for separation anxiety disorder
Exposure therapy for separation anxiety disorder
What is separation anxiety disorder?
What is exposure therapy?
Description and rationale
Types of exposure tasks
Features of the exposure task
How to create a fear and avoidance hierarchy
How to use subjective units of distress
How to carry out an exposure
Before the exposure
Implementing the exposure
After the exposure
Youth factors
Developmental level
Cultural considerations
Challenging issues
Youth resistance
Parental attitudes and behaviors
Clinician discomfort
Ethical considerations
Discussion
References
8 Exposure therapy for specific phobias in children and adolescents
Case example
Treatment plan I: assessment
Clinical interview and additional questionnaires
Behavioral assessment
Integration assessment results
Treatment plan II: how to do exposure
Treatment options
Exposure treatment: how does it work?
Features of a good step ladder
Fighting fear by facing fear
Tips and recommendations when doing exposure
Maintaining improvement
Involving the family
Tips and tricks
Challenging issues
Conclusion
References
Further Reading
9 Exposure therapy for children and adolescents with social anxiety disorder
Introduction to therapy structure
Introduction to case example
Session 1: building rapport, psychoeducation, orientation to treatment
Case example
Session 2: review of the three-component model of anxiety, goal setting, and constructing an anxiety/avoidance hierarchy
Case example
Session 3: cognitive restructuring
Case example
Session 4: social skills and assertiveness training
Case example
Sessions 5: first exposure practice
Case example
Sessions 6–11: continued exposure practice
Case example
Session 12: skill review, relapse prevention, celebration
Case example
Potential treatment challenges
Relevant therapy manuals
Summary
References
10 Exposure therapy for generalized anxiety disorder in children and adolescents
Before beginning exposures
Developing a fear hierarchy
Planning exposures: school-related GAD worries
Preparing youth for specific exposure tasks
Preparing parents/family
Preparing and coordinating with other individuals
Planning exposures: future-oriented GAD worries
Implementing exposure tasks
Problem-solving potential difficulties
Sample GAD fear hierarchies and suggested exposure tasks
Conclusion
References
11 Exposure with response prevention for obsessive-compulsive disorder in children and adolescents
Exposure therapy for obsessive-compulsive disorder in children and adolescents
Background of treatment approach
Chronology and components of exposure therapy for obsessive-compulsive disorder
Components of psychoeducation
Constructing a fear hierarchy
Coping skills
Conducting exposures
Relapse prevention
Factors complicating exposure therapy for obsessive-compulsive disorder
Insight and motivation
Family accommodation
Comorbid psychopathology
Surreptitious compulsions and therapy-interfering behaviors
Conclusion
References
Section III: Developmental considerations
12 Using exposure with young children
Overview of modifications to exposure for young children
Psycho-education and developing a formulation
Anxiety rating scale
Building a hierarchy
Designing exposure tasks
Implementing exposure
Challenging issues
Behavioral difficulties
Child refusing treatment
Parental factors and family dynamics
Conclusion
References
13 Using exposure with adolescents and youth adults
Using exposure with adolescents and young adults
Developmental stage of adolescence
Implications for exposure therapy
Working with parents in adolescent exposure therapy
Maintaining motivation
Developmentally appropriate treatment models for adolescents
Developmental phase of emerging adulthood
Developmental tasks of emerging adulthood
Implications for mental health and exposure treatment
Changing role of parents
Implications for parent work with young adults
Developmentally appropriate treatment models
Assessment
Clinician-administered interview
Measures of behavioral functioning
Parent and family functioning measures
Step-by-step treatment approach
Psychoeducation
Skill building
Exposure
Introduction to exposure
Use of confederates
Review and relapse prevention
Including parents in treatment sessions
Clinical examples
Course of treatment
References
Further reading
14 Involving family members in exposure therapy for children and adolescents
Family characteristics linked to youth anxiety and treatment outcomes
Psychopathology in the family
Modeling and verbal transfer of information
Parental overcontrol
Psychological control
Family accommodation
Rescue behavior
Parental cognitions about child anxiety
Family functioning
Caregiver strain/family burden
Practical recommendations
Attending to family context during assessment
Choosing a treatment format
Orienting families to treatment
Addressing family responses to obsessive-compulsive disorder/anxiety symptoms
Processing emotions
Withdrawing family accommodation
Managing difficult episodes
Eliminating secondary gain
Validating feelings and prompting coping
Rewarding effort
Targeting other familial influences on anxiety
Expanding families’ toolkit
Behavior management
Communication
Terminating treatment
References
Section IV: Adaptations for complex presentations
15 Transdiagnostic exposure-based intervention for anxiety and depression in children and adolescents
Transdiagnostic interventions for internalizing problems
What are transdiagnostic interventions?
Why target internalizing problems as a cluster?
Evidence base for transdiagnostic interventions for internalizing adults
What do transdiagnostic interventions for internalizing problems look like in youth?
Conceptualizing avoidance and withdrawal as maladaptive coping responses to stress
What differentiates a transdiagnostic approach from traditional cognitive-behavioral therapy for youth anxiety?
Advantages of a transdiagnostic approach with children and adolescents
Transdiagnostic brief behavioral therapy for pediatric anxiety and depression
Development of brief behavioral therapy
Brief behavioral therapy evidence base
Brief behavioral therapy implementation
Case example: Emmy
Session 1: Psychoeducation and treatment rationale
Session 2: Relaxation and coping with negative affect
Session 3: Problem-solving skills training
Session 4: Reducing avoidance and setting goals
Sessions 5–10: Increasing engagement and activation
Sessions 11 and 12: Review and relapse prevention
General considerations for the implementation of brief behavioral therapy
Managing complex symptom presentations
Safety assessments and unexpected events
Treatment priorities
Distress ratings
Parental involvement
Current and future directions for use of trandiagnostic interventions in internalizing youth
References
16 Overcoming challenges in exposure therapy
Trouble-shooting exposures with children and adolescents
Misappraisal of exposure distress
Step #1: keep calm and carry on
Step #2: step back but do not stop
Step #3: processing the experience
Patient resistance to completing exposures
Short-term exposure distress is perceived to be greater than the long-term benefit
Symptoms do not cause distress, so why participate in treatment
Trouble-shooting exposures with parents and caregivers
Difficulty understanding underlying principles of exposure therapy
Difficulty implementing exposures outside of therapy sessions
Persistent accommodation
Unwillingness to monitor and/or perform exposures outside of therapy visits
Pushing too little or too much during exposure homework
Trouble-shooting exposures with clinicians
Access to resources to conduct exposures
Access to education/training/experience to conduct exposures
Conclusion
References
17 Acceptance and commitment therapy–enhanced exposures for children and adolescents
Current best practices: A brief overview of exposure and response prevention
What is acceptance and commitment therapy?
The evidence for acceptance and commitment therapy and acceptance and commitment therapy+exposure and response prevention a...
How to integrate acceptance and commitment therapy with exposure and response prevention for children and adolescents with ...
Setting the groundwork for effective treatment
Psychoeducation
Values
Cognitive defusion
Acceptance
Identifying productive exposure tasks
Integrating the family system into treatment
A brief primer on parenting styles
Troubleshooting
Conclusions
References
Author Index
Subject Index
Back Cover

Citation preview

EXPOSURE THERAPY FOR CHILDREN WITH ANXIETY AND OCD

EXPOSURE THERAPY FOR CHILDREN WITH ANXIETY AND OCD Clinician’s Guide to Integrated Treatment

Edited by

TARA S. PERIS University of California, Los Angeles, Los Angeles, CA, United States

ERIC A. STORCH Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States

JOSEPH F. MCGUIRE Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2020 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN: 978-0-12-815915-6 For Information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Nikki Levy Acquisition Editor: Nikki Levy Editorial Project Manager: Barbara Makinster Production Project Manager: Paul Prasad Chandramohan Cover Designer: Matthew Limbert Typeset by MPS Limited, Chennai, India

Dedication To Joel, Kiran, and Maya, and to the children and families who have made this work possible. Tara S. Peris To those with OCD or anxiety and their loved ones (now and in the future); I hope that this book provides guidance to clinicians on how best to support you. And, to my loves (Noah, Ellie, Maya, and Jill). Eric A. Storch To my family who serve as a source of unwavering love and support, and to my mentors who are a source of encouragement and inspiration. Joseph F. McGuire

Contents

List of contributors Preface

xiii xvii

Section I Basics of exposure therapy for children and adolescents 1. History and theoretical underpinnings of exposure therapy

3

Meghan Vinograd and Michelle G. Craske

Systematic desensitization The habituation model The inhibitory learning model Common techniques Specific techniques Exposure therapy for children and adolescents Conclusion Acknowledgment References Further reading

4 7 9 10 13 14 17 17 17 20

2. Efficacy of exposure-based cognitive behavioral therapy for youth anxiety and obsessive-compulsive disorder

21

Katherine C. Bergez, Ana C. Ramirez, Stacey C. Grebe, Mayra I. Perez, Andres G. Viana, Eric A. Storch and Sophie C. Schneider

Introduction Overview of cognitive behavioral therapy for youth anxiety disorders Examples of key interventions for youth anxiety disorders Delivery format considerations for anxiety disorder treatment Impact of clinical characteristics on anxiety disorder treatment Overview of cognitive behavioral therapy for youth obsessive compulsive disorder Examples of key interventions for obsessive-compulsive disorder Delivery format considerations for obsessive compulsive disorder treatment Impact of clinical characteristics on obsessive compulsive disorder treatment Conclusion References

vii

21 22 22 23 25 26 27 28 29 30 31

viii

Contents

3. Psychoeducation for exposure therapy

39

Cassie Lavell, Jacinda Cadman, Allison Waters and Lara Farrell

Psychoeducation on exposure therapy Providing a treatment rationale Implementing exposure therapy (and response prevention) Maximizing exposure therapy outcomes Overcoming challenges encountered in psychoeducation for exposure therapy Concluding remarks Appendix 1 References Further reading

4. Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy

39 46 48 54 60 63 64 64 67

69

Tara S. Peris

Evidence-based assessment to build a hierarchy Interviews and measures for the practicing clinician Youth and parent report of symptom severity and impairment in anxiety and OCD Translating assessment into treatment Introducing the hierarchy Establishing anchors Getting creative with it Putting your hierarchy to use Adjustments throughout treatment References

5. Developing and implementing successful exposure-based interventions

70 70 74 76 78 79 80 81 82 82

85

Dean McKay

Basic illustrative case Identifying target stimuli Developing the hierarchy Developing and implementing exposure exercises Barriers to successful exposure therapy Planning for termination Conclusion References

86 88 90 94 104 108 108 109

Contents

ix

Section II Implementing exposure by diagnosis 6. Exposure therapy for childhood selective mutism: principles, practices, and procedures

113

Jami M. Furr, Amanda L. Sanchez, Natalie Hong and Jonathan S. Comer

Exposure therapy for selective mutism: developmental and clinical considerations Key elements of exposure therapy for childhood selective mutism Challenging issues in exposure therapy for childhood selective mutism Conclusion and future directions References Further reading

7. Exposure therapy for separation anxiety disorder

115 117 137 139 140 142

143

Kara B. West, Joanie Wilbanks and Cynthia Suveg

Exposure therapy for separation anxiety disorder What is separation anxiety disorder? What is exposure therapy? Features of the exposure task How to carry out an exposure Youth factors Challenging issues Discussion References

8. Exposure therapy for specific phobias in children and adolescents

143 144 145 147 149 154 156 159 160

165

Lynn Mobach, Ella Oar and Jennifer L. Hudson

Case example Treatment plan I: assessment Clinical interview and additional questionnaires Behavioral assessment Integration assessment results Treatment plan II: how to do exposure Exposure treatment: how does it work? Features of a good step ladder Tips and recommendations when doing exposure Maintaining improvement Involving the family Challenging issues Conclusion References Further Reading

166 166 167 169 171 171 174 175 178 181 182 184 186 186 190

x

Contents

9. Exposure therapy for children and adolescents with social anxiety disorder

193

Sarah Ryan Radtke, Marlene V. Strege and Thomas H. Ollendick

Introduction to therapy structure Session 1: building rapport, psychoeducation, orientation to treatment Session 2: review of the three-component model of anxiety, goal setting, and constructing an anxiety/avoidance hierarchy Session 3: cognitive restructuring Session 4: social skills and assertiveness training Sessions 5: first exposure practice Sessions 6 11: continued exposure practice Session 12: skill review, relapse prevention, celebration Potential treatment challenges Relevant therapy manuals Summary References

10. Exposure therapy for generalized anxiety disorder in children and adolescents

195 196 199 202 205 207 211 213 214 217 217 218

221

Jordan P. Davis, Sophie A. Palitz, Lesley A. Norris, Katherine E. Phillips, Margaret E. Crane and Philip C. Kendall*

Before beginning exposures Developing a fear hierarchy Planning exposures: school-related GAD worries Planning exposures: future-oriented GAD worries Implementing exposure tasks Problem-solving potential difficulties Sample GAD fear hierarchies and suggested exposure tasks Conclusion References

11. Exposure with response prevention for obsessive-compulsive disorder in children and adolescents

222 223 226 237 239 240 241 241 242

245

Monica S. Wu, Hardian Thamrin and Jocelyn Pe´rez

Exposure therapy for obsessive-compulsive disorder in children and adolescents Background of treatment approach Chronology and components of exposure therapy for obsessive-compulsive disorder Factors complicating exposure therapy for obsessive-compulsive disorder Conclusion References

245 246 248 260 264 265

Contents

xi

Section III Developmental considerations 12. Using exposure with young children

271

Amita D. Jassi and Z. Kindynis

Overview of modifications to exposure for young children Psycho-education and developing a formulation Anxiety rating scale Building a hierarchy Designing exposure tasks Implementing exposure Challenging issues Conclusion References

13. Using exposure with adolescents and youth adults

273 274 280 280 282 284 288 290 291

295

Shannon M. Bennett and Anne Marie Albano

Using exposure with adolescents and young adults Developmental stage of adolescence Developmental phase of emerging adulthood Assessment Step-by-step treatment approach Clinical examples References Further reading

14. Involving family members in exposure therapy for children and adolescents

295 296 299 304 307 314 320 322

323

Nicole E. Caporino

Family characteristics linked to youth anxiety and treatment outcomes Practical recommendations References

324 334 348

Section IV Adaptations for complex presentations 15. Transdiagnostic exposure-based intervention for anxiety and depression in children and adolescents

361

Michelle Rozenman, Araceli Gonzalez and V. Robin Weersing

Transdiagnostic interventions for internalizing problems Case example: Emmy

361 369

xii

Contents

General considerations for the implementation of brief behavioral therapy Current and future directions for use of trandiagnostic interventions in internalizing youth References

16. Overcoming challenges in exposure therapy

376 378 380

383

Rachel Canella, Joey Ka-Yee Essoe, Marco Grados and Joseph F. McGuire

Trouble-shooting exposures with children and adolescents Trouble-shooting exposures with parents and caregivers Trouble-shooting exposures with clinicians Conclusion References

17. Acceptance and commitment therapy enhanced exposures for children and adolescents

384 393 399 402 403

405

Anna E. Allmann, Lisa W. Coyne, Rebecca Michel and Robert McGowan

Current best practices: A brief overview of exposure and response prevention What is acceptance and commitment therapy? The evidence for acceptance and commitment therapy and acceptance and commitment therapy 1 exposure and response prevention approaches How to integrate acceptance and commitment therapy with exposure and response prevention for children and adolescents with anxiety disorders Identifying productive exposure tasks Integrating the family system into treatment A brief primer on parenting styles Troubleshooting Conclusions References

Author Index Subject Index

407 409 410 413 419 420 421 423 425 428

433 445

List of contributors Anne Marie Albano Columbia University Medical Center and New York Presbyterian Hospital Youth Anxiety Center, New York, NY, United States Anna E. Allmann Columbia University Clinic for Anxiety and Related Disorders, Columbia University, Tarrytown, NY, United States Shannon M. Bennett Weill Cornell Medicine and New York Presbyterian Hospital Youth Anxiety Center, New York, NY, United States Katherine C. Bergez Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States Jacinda Cadman School of Applied Psychology, Griffith University, Gold Coast Campus, QLD, Australia Rachel Canella Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States Nicole E. Caporino Department Washington, DC, United States

of

Psychology,

American

University,

Jonathan S. Comer Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States Lisa W. Coyne McLean OCD Institute for Children and Adolescents, Harvard Medical School, Middleborough, MA, United States Margaret E. Crane

Temple University, Philadelphia, PA, United States

Michelle G. Craske Departments of Psychology and Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, United States Jordan P. Davis

Temple University, Philadelphia, PA, United States

Joey Ka-Yee Essoe Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States Lara Farrell School of Applied Psychology, Griffith University, Gold Coast Campus, QLD, Australia Jami M. Furr Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States Araceli Gonzalez California State University Long Beach, Long Beach, CA, United States Marco Grados Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States Stacey C. Grebe Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States

xiii

xiv

List of contributors

Natalie Hong Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States Jennifer L. Hudson Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia Amita D. Jassi National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom Philip C. Kendall Temple University, Philadelphia, PA, United States Z. Kindynis National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom Cassie Lavell School of Applied Psychology, Griffith University, Gold Coast Campus, QLD, Australia Robert McGowan

The University of Scranton, Scranton, PA, United States

Joseph F. McGuire Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States Dean McKay Department of Psychology, Fordham University, Bronx, NY, United States Rebecca Michel McLean OCD Institute for Children and Adolescents, Harvard Medical School, Middleborough, MA, United States Lynn Mobach Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia Lesley A. Norris

Temple University, Philadelphia, PA, United States

Ella Oar Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia Thomas H. Ollendick Virginia Polytechnic Institute and State University, Blacksburg, VA, United States Sophie A. Palitz

Temple University, Philadelphia, PA, United States

Jocelyn Pe´rez Children’s Hospital Los Angeles, CA, United States Mayra I. Perez Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States Tara S. Peris UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States Katherine E. Phillips

Temple University, Philadelphia, PA, United States

Sarah Ryan Radtke Virginia Polytechnic Institute and State University, Blacksburg, VA, United States Ana C. Ramirez Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States Michelle Rozenman University of Denver/UCLA Semel Institute Neuroscience & Human Behavior, Los Angeles, CA, United States

for

List of contributors

xv

Amanda L. Sanchez Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States Sophie C. Schneider Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States Eric A. Storch Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States Marlene V. Strege Virginia Polytechnic Institute and State University, Blacksburg, VA, United States Cynthia Suveg Psychology Department, University of Georgia, Athens, GA, United States Hardian Thamrin United States

Department of Psychology, Arizona State University, AZ,

Andres G. Viana Department of Psychology, University of Houston, Houston, TX, United States Meghan Vinograd Department of Psychology, University of California, Los Angeles, CA, United States Allison Waters School of Applied Psychology, Griffith University, Gold Coast Campus, QLD, Australia V. Robin Weersing Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, CA, United States Kara B. West Psychology Department, University of Georgia, Athens, GA, United States Joanie Wilbanks United States

Psychology Department, University of Georgia, Athens, GA,

Monica S. Wu UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States

Preface Over the last two decades, the treatment literature for child and adolescent anxiety and obsessive-compulsive disorder (OCD) has grown immensely (Comer, Hong, Poznanski, Silva, & Wilson, 2019; Freeman et al., 2018; Higa-McMillan, Nakamura, Morris, Jackson, & Slavin, 2015). Using increasingly rigorous methods, this body of research has cemented the status of cognitive-behavior therapy (CBT) as a well-established treatment for both child and adolescent anxiety and OCD. Moreover, it has begun to examine novel applications (e.g., internet-based delivery; Spence et al., 2011), augmentation (D-Cycloserine for OCD (Storch et al., 2016), and modular intervention strategies (Chorpita & Weisz, 2009) that are meant to expand access to evidence-based care and to optimize clinical outcomes. Yet, as the field continues to evolve, one feature remains constant and that is the emphasis on the role of exposure in treatment. Exposure is among the most important basic principles in psychology. Dating to the work of Joseph Wolpe in the 1960s, and Mary Cover Jones before him, it has evolved in both theory and practice through decades of study in learning and behavior, clinical intervention, and behavioral neuroscience. Today, exposure is incorporated in virtually every evidence-based protocol for child and adolescent anxiety and OCD (Chorpita, Daleiden, & Weisz, 2005). Significant clinical improvements are observed following its introduction in treatment (Peris et al., 2015), and the technique is viewed widely as the key to successful treatment (Barlow, Gorman, Shear, & Woods, 2000; Bouchard, Mendlowitz, ¨ st, Svensson, Hellstro¨m, & Coles, & Franklin, 2004; Hudson, 2005; O Lindwall, 2001; Schniering, Hudson, & Rapee, 2000). Yet as the literature related to exposure has evolved, the guidance for practicing clinicians has not always kept pace. Our goal in developing this book was to provide up-to-date, empirically informed guidance on best practices for implementing exposure with youth with anxiety and OCD. Despite its central role in treatment for youth anxiety and OCD, technique, we were struck by how few resources exist to guide clinicians in its practical application. Beyond knowing that exposure is the technique one should use when treating anxiety and OCD, there is little to guide clinicians in what it should actually look like in practice. There are few guides that offer practical strategies for maximizing success, tailoring by age, and anticipating and

xvii

xviii

Preface

troubleshooting common difficulties that arise. Given that exposure, at the most basic level, involves encouraging young clients to practice and tolerate scary situations, this is no small matter. The oversight is also unfortunate, given the many recent advances in basic science and experimental research that might inform how these techniques can and should be used in treatment (Craske et al., 2008; Kircanski, Lieberman, & Craske, 2012). Indeed, a growing body of research has examined the mechanisms underlying how we learn to be fearful or distressed and how we “unlearn” these associations (McGuire et al., 2016). Such work has debunked many of the prevailing theories of how and why exposure tasks work, in turn offering new evidencebased models with direct implications for practicing clinicians (Baker et al., 2010; Culver, Stoyanova, & Craske, 2012; Hayes, 2008; Kircanski et al., 2012; Norton, Hayes-Skelton, & Klenck, 2011). Related work in developmental neuroscience offers further guidance for how we might tailor our approach based on the age of the patient (Pattwell et al., 2016; Schiller, Raio, & Phelps, 2012). With these advances in mind, we have structured this book to provide both a foundation of understanding about how and why exposure works and the evidence supporting its application and also a users’ guide for treating children of different ages and clinical presentations. The first part of this book provides background information important for all practicing clinicians. As effective implementation is predicated on understanding the principles of learning and behavior that underlie exposure therapy, we begin with a historical overview of the theory guiding exposure practice (Chapter 2: Efficacy of exposure-based cognitive behavioral therapy for youth anxiety and obsessive-compulsive disorder). We then provide an overview of the evidence-base for exposure therapy in treating child and adolescent OCD and anxiety (Chapter 3: Psychoeducation for exposure therapy) and strategies for getting started in treatment, including psychoeducation (Chapter 4: Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy), developing a symptom hierarchy (Chapter 5: Developing and implementing successful exposure-based interventions), and crafting individual exposure exercises (Chapter 6: Exposure therapy for childhood selective mutism: principles, practices, and procedures). The second part of the book considers how to apply the technique to different disorders. What do you do when your client will not speak to you (as in selective mutism)? How do you develop an exposure for future-oriented concerns where the outcome cannot be assessed immediately (as in generalized anxiety disorder [GAD]-related anxiety about the environment or the economy)? Covering selective mutism (Chapter 7: Exposure therapy for separation anxiety disorder), separation anxiety disorder (Chapter 8: Exposure therapy for specific phobias

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in children and adolescents), specific phobia (Chapter 9: Exposure therapy for children and adolescents with social anxiety disorder), social phobia (Chapter 10: Exposure therapy for generalized anxiety disorder in children and adolescents), GAD (Chapter 11: Exposure with response prevention for obsessive-compulsive disorder in children and adolescents), and OCD (Chapter 12: Using exposure with young children), this section of the book explicates strategies for designing and implementing exposures across the most common disorders for children and adolescents. The third section of the book tackles developmental considerations in depth. Focusing on treatment adaptations for very young children (Chapter 13: Using exposure with adolescents and youth adults) and also on those transitioning to adulthood (Chapter 14: Involving family members in exposure therapy for children and adolescents), these chapters guide practitioners in how to individualize treatment and maintain engagement and buy-in. Chapter 15, Transdiagnostic exposure-based intervention for anxiety and depression in children and adolescents provides an overview of how to involve family members in treatment for anxiety and OCD, recognizing that parents are often anxious and highly stressed themselves. In the final section of the book, we consider adaptations that may be needed for more complex cases. This includes a discussion of the use of exposure in transdiagnostic treatment (Chapter 16: Overcoming challenges in exposure therapy) as well as ACT-enhanced approaches (Chapter 17: Acceptance and commitment therapy enhanced exposures for children and adolescents) and clinical troubleshooting (Chapter 18). In undertaking all of this, our goal was to draw on the expertise of leaders in the field of youth anxiety and OCD treatment. We are immensely fortunate and grateful that they so readily agreed to participate, and their work here speaks for itself. As seasoned clinicians ourselves, we were amazed by their clinical wisdom, and by how much we continued to learn from their excellent work and advice in this process. We hope that you, too, find this guide valuable, and that it informs the rewarding, fun, and often challenging work that exposure therapy involves.

References Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour Research and Therapy, 48(11), 1139 1143. Available from https://doi.org/ 10.1016/j.brat.2010.07.009. Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their corn or their combination for panic disorder: A

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randomized controlled trial. Journal of the American Medical Association, 283(19), 2529 2536. Available from https://doi.org/10.1001/jama.283.19.2529. Bouchard, S., Mendlowitz, S. L., Coles, M. E., & Franklin, M. (2004). Considerations in the use of exposure with children. Cognitive and Behavioral Practice, 11(1), 56 65. Available from https://doi.org/10.1016/S1077-7229(04)80007-5. Chorpita, B. F., Daleiden, E. L., & Weisz, J. R. (2005). Identifying and selecting the common elements of evidence based interventions: A distillation and matching model. Mental Health Services Research, 7(1), 5 20. Available from https://doi.org/10.1007/s11020-0051962-6. Chorpita, B. F., & Weisz, J. R. (2009). Modular approach to therapy for children with anxiety, depression, trauma, or conduct problems (MATCH-ADTC). PracticeWise. Comer, J. S., Hong, N., Poznanski, B., Silva, K., & Wilson, M. (2019). Evidence base update on the treatment of early childhood anxiety and related problems. Journal of Clinical Child and Adolescent Psychology, 48(1), 1 15. Available from https://doi.org/10.1080/ 15374416.2018.1534208. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5 27. Available from https://doi.org/10.1016/j.brat.2007.10.003. Culver, N. C., Stoyanova, M., & Craske, M. G. (2012). Emotional variability and sustained arousal during exposure. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 787 793. Available from https://doi.org/10.1016/j.jbtep.2011.10.009. Freeman, J., Benito, K., Herren, J., Kemp, J., Sung, J., Georgiadis, C., & Garcia, A. (2018). Evidence base update of psychosocial treatments for pediatric obsessive-compulsive disorder: Evaluating, improving, and transporting what works. Journal of Clinical Child and Adolescent Psychology, 47(5), 669 698. Available from https://doi.org/10.1080/ 15374416.2018.1496443. Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of acceptance and commitment therapy and traditional cognitive behavioral therapy. Clinical Psychology: Science and Practice, 15(4), 286 295. Available from https://doi.org/ 10.1111/j.1468-2850.2008.00139.x. Higa-McMillan, C. K., Nakamura, B. J., Morris, A., Jackson, D. S., & Slavin, L. (2015). Predictors of use of evidence-based practices for children and adolescents in usual care. Administration and Policy in Mental Health and Mental Health Services Research, 42(2), 373 383. Available from https://doi.org/10.1007/s10488-014-0578-9. Hudson, J. L. (2005). Efficacy of cognitive-behavioural therapy for children and adolescents with anxiety disorders. Behaviour Change, 3(6). Available from https://doi.org/10.1375/ bech.2005.22.2.55. Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words: Contributions of language to exposure therapy. Psychological Science, 23(10), 1086 1091. Available from https://doi.org/10.1177/0956797612443830. McGuire, J. F., Orr, S. P., Essoe, J. K. Y., McCracken, J. T., Storch, E. A., & Piacentini, J. (2016). Extinction learning in childhood anxiety disorders, obsessive compulsive disorder and post-traumatic stress disorder: Implications for treatment. Expert Review of Neurotherapeutics, 16(10), 1155 1174. Available from https://doi.org/10.1080/ 14737175.2016.1199276. Norton, P. J., Hayes-Skelton, S. A., & Klenck, S. C. (2011). What happens in session does not stay in session: Changes within exposures predict subsequent improvement and dropout. Journal of Anxiety Disorders, 225(5), 654 660. Available from https://doi.org/ 10.1016/j.janxdis.2011.02.006. ¨ st, L. G., Svensson, L., Hellstro¨m, K., & Lindwall, R. (2001). One-session treatment of speO cific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 77(3), 504 516. Available from https://doi.org/10.1037/0022-006X.69.5.814.

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Pattwell, S. S., Liston, C., Jing, D., Ninan, I., Yang, R. R., Witztum, J., & Lee, F. S. (2016). Dynamic changes in neural circuitry during adolescence are associated with persistent attenuation of fear memories. Nature Communications, 7, 11475. Available from https:// doi.org/10.1038/ncomms11475. Peris, T. S., Compton, S. N., Kendall, P. C., Birmaher, B., Sherrill, J., March, J., & Piacentini, J. (2015). Trajectories of change in youth anxiety during cognitive-behavior therapy. Journal of Consulting and Clinical Psychology, 83(2), 239 252. Available from https://doi. org/10.1037/a0038402. Schiller, D., Raio, C. M., & Phelps, E. A. (2012). Extinction training during the reconsolidation window prevents recovery of fear. Journal of Visualized Experiments. Available from https://doi.org/10.3791/3893. Schniering, C. A., Hudson, J. L., & Rapee, R. M. (2000). Issues in the diagnosis and assessment of anxiety disorders in children and adolescents. Clinical Psychology Review, 20(4), 453 478. Available from https://doi.org/10.1016/S0272-7358(99)00037-9. Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., & Kenardy, J. (2011). A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79(5), 629 642. Available from https://doi.org/10.1037/a0024512. Storch, E. A., Wilhelm, S., Sprich, S., Henin, A., Micco, J., Small, B. J., & Geller, D. A. (2016). Efficacy of augmentation of cognitive behavior therapy with weight-adjusted Dcycloserine vs placebo in pediatric obsessive-compulsive disorder: A randomized clinical trial. JAMA Psychiatry, 73(8), 779 788. Available from https://doi.org/10.1001/ jamapsychiatry.2016.1128.

C H A P T E R

1 History and theoretical underpinnings of exposure therapy* Meghan Vinograd1 and Michelle G. Craske2 1

Department of Psychology, University of California, Los Angeles, CA, United States, 2Departments of Psychology and Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, United States

Exposure therapy is an empirically supported treatment for anxiety, posttraumatic stress, and obsessive compulsive disorders. The Society of Clinical Psychology of the American Psychological Association (APA) designates exposure therapy for specific phobias as having strong research support, indicating that it is a well-established treatment (APA Presidential Task Force on Evidence-Based Practice, 2006). Prolonged exposure for posttraumatic stress disorder and exposure and response prevention for obsessive compulsive disorder, two forms of exposure therapy, similarly have strong research support per these criteria. In a meta-analysis of 111 treatment outcome studies, exposure was designated as a well-established and first-line treatment for childhood and adolescent anxiety (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Exposure has been identified as an essential component of cognitive behavior therapy for successfully treating anxious youth (Kazdin & Weisz, 1998; Kendall et al., 2005). Indeed, in a sample of anxious youth,

* The preparation of this manuscript was supported by the National Institute of Mental Health of the National Institutes of Health under award number T32MH015750 to Meghan Vinograd.

Exposure Therapy for Children with Anxiety and OCD DOI: https://doi.org/10.1016/B978-0-12-815915-6.00001-9

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Copyright © 2020 Elsevier Inc. All rights reserved.

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the introduction of exposure exercises was followed by a significant increase in the rate of progress during subsequent treatment as indexed by measures of anxiety symptom severity and global functioning (Peris et al., 2015). One study found that the percentage of sessions focused on exposures was positively related to improvement in functioning from pre- to post-treatment among youth with anxiety disorders, whereas the use of other anxiety management strategies was negatively related to this improvement (Voort, Svecova, Jacobsen, & Whiteside, 2010). Finally, greater time spent on more difficult exposure exercises during treatment predicted better outcomes in a sample of children and adolescents with anxiety disorders (Peris et al., 2017). The practice of exposure therapy has evolved over time in conjunction with shifts in the theory that is used to explain how and why it is effective. It has been argued that a clinician’s understanding of the theory that underlies exposure therapy is important in order for the treatment to be most successful (Abramowitz, 2013). The purpose of this chapter is to provide the reader with foundational knowledge of the history and theoretical underpinnings of exposure therapy. First, we review the theory and procedure of systematic desensitization, considered a precursor to modern exposure therapy. Second, we describe the habituation model of exposure therapy. We then present the most recent model of exposure therapy: the inhibitory learning model. For each, we discuss how theory influences the clinical practice of exposure therapy under the given model. Lastly, we review considerations for conducting exposure therapy with children and adolescents as related to current theory.

Systematic desensitization In the early- to mid-20th century, behaviorism emerged as a contrast to psychoanalytic theory, which until that point was the predominant theoretical framework used for the explanation and treatment of mental disorders. Behaviorists argued the importance of examining overt behavior, rather than unconscious or covert processes. At this time, there was a renewed interest in the principles of Pavlovian conditioning, sometimes referred to as classical conditioning. In Pavlovian conditioning, when a neutral stimulus (known as the conditional stimulus or CS) is repeatedly paired with an aversive stimulus (unconditional stimulus or US), it will come to elicit a conditional response (CR) even in the absence of the US. For example, the presentation of a neutral tone paired with an electric shock will eventually elicit a fear response in the organism, even when the tone is presented without the shock. This procedure is known as fear acquisition. In fear extinction, the repeated presentation of the CS without the US will lead to an eventual decline in

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the CR. Specifically, extinction is thought to occur when there is a mismatch between the expectancy of an event and its nonoccurrence (Rescorla & Wagner, 1972). Exposure therapy is largely based on the principles of Pavlovian conditioning. Joseph Wolpe began disseminating systematic desensitization as a treatment for phobias and other types of anxiety in the 1960s, alongside the emergence of behaviorism. The experimental work of Mary Cover Jones decades earlier, however, provided an important empirical basis for systematic desensitization. In a case study of a young child named Peter who had a fear of rats, Jones demonstrated that presenting stimuli that resembled rats (e.g., a fur coat, a rabbit) to Peter while he was eating led to a reduced fear response (1924a, 1924b).1 The studies of Peter are an illustration of the principle of reciprocal inhibition, on which systematic desensitization is based. Reciprocal inhibition dictates that the pairing of a fear-provoking stimulus with a response that is physiologically incompatible with fear will inhibit the fear response, thereby reducing it (Wolpe, 1968). In her experiments with Peter, Jones used feeding as the response incompatible with fear. Wolpe tested this same technique in cats that had undergone a Pavlovian fear-conditioning procedure. By administering electric shocks to the cats while in their cages, they eventually grew to fear the cage alone. Wolpe then fed the cats while in their cages as a test of reciprocal inhibition, and indeed, the cats eventually demonstrated a reduced fear response (Wolpe, 1952, 1954). Next, Wolpe began to conduct systematic desensitization with adult human subjects, most of whom had phobias. Wolpe hypothesized that after this procedure, the association between the stimulus and the anxiety response would be weakened, or inhibited, so that encountering the stimulus in vivo would no longer evoke anxiety (1961). Wolpe’s systematic desensitization procedure involved three stages: relaxation training, construction of anxiety hierarchies, and desensitization (1961). In the first stage, patients were trained in deep muscle relaxation, which was to thought to be physiologically incompatible with a fearful state. Wolpe argued that deep muscle relaxation was a convenient behavior to inhibit the anxiety response (1961), and he modeled the relaxation procedures off of those used by Edmund Jacobson (1939). Over the course of six sessions, the clinician would guide the patient in tensing and then relaxing various muscle groups, encouraging the patient to go “beyond” the point of typical relaxation (Wolpe, 1961). Patients were also encouraged to practice the relaxation procedure at home between sessions. 1 It should be noted, however, that other procedures were tested simultaneously, including other children modeling approach of and interest in the feared stimuli. Therefore, one cannot conclude that having Peter eat while in the presence of the feared stimuli was the sole mechanism underlying his reduced fear response.

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In the second stage of Wolpe’s systematic desensitization procedure, clinicians would guide patients in creating anxiety hierarchies. Wolpe noted that this stage could be conducted in the same sessions as the relaxation training (1961). After a thorough discussion of feared stimuli and situations, items were then ordered from most to least anxietyprovoking and grouped thematically, meaning that a given patient may have had more than one anxiety hierarchy. Wolpe noted the importance of including items on the hierarchy that evoke only a minimal fear response and can therefore be counteracted by the patient’s relaxation ability (1961). Systematic desensitization was conducted in a graduated fashion, that is, anxiety reduction was achieved for the items lower on the hierarchy before moving on to higher items. This graduated approach resulted in items higher on the hierarchy provoking less anxiety than they had at the start of treatment. The patient’s relaxation response could therefore successfully inhibit the anxiety response to higher order items, a necessary element of systematic desensitization. The third and final stage was the desensitization procedure. In contrast to the research on children and animals, Wolpe’s procedure for adults typically utilized imaginal techniques rather than in vivo exposure. Patients were asked to vividly call to mind the feared stimulus and then relax in an alternating fashion, and indicate any anxiety experienced by lifting their finger (Wolpe, 1961). Therapists would move to the next hierarchy item when the patient indicated experiencing no distress to the previous item. Wolpe reported significant success in treating anxious patients with this procedure, with 90% of his cases either “apparently cured” or “much improved” according to one report (1954). Treatment success was typically measured via patients’ reports of their responses to feared stimuli outside the therapy setting and as such, was relatively unstandardized (Wolpe, 1961).2 Wolpe argued that reciprocal inhibition was the mechanism of change underlying systematic desensitization, rather than extinction or psychoanalytical processes (1954).3 According to reciprocal inhibition, imagining the feared stimuli while in a relaxed state was integral to the procedure’s success. In an experimental study of Wolpe’s procedure using a sample of individuals with snake phobia, the systematic desensitization group demonstrated a significantly greater reduction in posttreatment avoidance behavior than the graded exposure and no-treatment control groups, as well as a group that completed 2 Rachman presents a successful case study of systematic desensitization using both imaginal and in vivo exposures, an extension of the original Wolpe procedure (1959). 3 Others theorized that the effects of systematic desensitization may be due, at least in part, to nonspecific treatment effects (Kazdin & Wilcoxon, 1976) or to the activation of unconscious fantasies (Silverman, Frank, & Dachinger, 1974).

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systematic desensitization using nonsnake stimuli (Davison, 1968). This study lent support to reciprocal inhibition (referred to as counterconditioning by the author) as the key mechanism underlying systematic desensitization, rather than exposure or relaxation alone. Later work, however, demonstrated that exposure to feared stimuli led to fear reduction without the relaxation component (Dawson & McMurray, 1978; Gillan & Rachman, 1974; Waters, McDonald, & Koresko, 1972), suggesting that reciprocal inhibition may not have been the key mechanism underlying systematic desensitization.4 Further, there exists mixed evidence for the utility of imaginal exposure over in vivo exposure (Foa & Kozak, 1986), including in the case of phobias (Mathews, 1978). For these reasons, systematic desensitization fell out of favor as a frontline treatment for anxiety disorders, leading to the development of modernday exposure therapy.

The habituation model As the use of systematic desensitization declined, the habituation model emerged as the predominant approach to exposure therapy (Mathews, 1971). Habituation in the context of exposure therapy refers to response decrement, namely, a decrease in fear or anxiety. Exposure therapy using the habituation model begins with the creation of a fear hierarchy, similar to stage two of Wolpe’s systematic desensitization procedure. Throughout construction of the hierarchy, clinicians elicit subjective units of distress (SUDs; Wolpe, 1973) ratings for each trigger. SUDs ratings can be on any scale, although a smaller range of values (e.g., 0 10) may be useful when working with children and adolescents (Kendall et al., 2005). Similar to systematic desensitization, exposure therapy under the habituation model is conducted in a graduated fashion, in which the initial exposures are associated with a low SUDs rating. Treatment protocols based in part on the habituation model suggest that exposures should be terminated when at least a 50% reduction in SUDs is achieved (Foa, Hembree, & Rothbaum, 2007). Clinicians also use SUDs ratings as indicators to move on to the next item on the patient’s fear hierarchy. Therefore the patient’s level of fear or anxiety guides each individual exposure as well as the overall course of therapy under the habituation model. Emotional processing theory (EPT; Foa & Kozak, 1986; Foa & McNally, 1996; Rachman, 1980) proposes that habituation is one mechanism underlying exposure therapy. In EPT, it is posited that fear is represented in 4 For cases in which relaxation was not used, Wolpe believed that the therapist acted as the reciprocal inhibitor of the fear response (M.G. Craske, personal communication).

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memory as a set of propositions about the feared stimulus, the associated response, and the meaning of the stimulus and response (together referred to as a fear structure; Foa & Kozak, 1986). Exposure therapy activates fear structures and integrates information that is incompatible with them as a form of corrective learning. This incompatible information may take the form of habituation of physiological arousal to the feared stimulus or a change in the meaning of the feared stimulus or the response, such as a reduction in the perceived likelihood of harm (Foa & Kozak, 1986). Within-session physiological habituation to the feared stimulus may enable the integration of corrective information about the meaning of the stimulus or response, leading to between-session habituation. According to EPT, three of the most important predictors of exposure therapy outcome are initial fear activation, between-session habituation, and within-session habituation (Foa & Kozak, 1986). Initial fear activation refers to the patient’s level of fear to the object or situation during the first exposure trial. Greater initial fear of the given exposure target is thought to be predictive of treatment success because activation of the fear structure is a necessary element of emotional processing (Foa & Kozak, 1986). Fear reduction over both the course of individual therapy sessions (within-session habituation) and treatment (between-session habituation) are proposed as two additional predictors of favorable treatment outcome. Both forms of habituation are thought to indicate successful integration of new information toward the formation of a new nonfear structure. In the laboratory, habituation may be indexed via decreased psychophysiological responding or lower SUDs ratings over time (Foa & Kozak, 1986). In the therapy setting, habituation is measured via SUDs ratings, given that tools for measuring physiological responding are not always available for use in treatment. Evidence for the role of initial fear activation, between-session habituation and within-session habituation as predictors of treatment outcome is mixed. Foa and Kozak (1986) review a number of studies that lend support to the utility of these indices as predictors of successful exposure therapy in clinical samples, including specific phobia, agoraphobia, and obsessive compulsive disorder. More recently, however, reviews have questioned the existing evidence for these indicators as useful predictors (Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). According to a review by Craske et al., positive evidence for the relation between initial fear activation and treatment outcomes is limited to heart rate, and other studies have demonstrated either no relation with other treatment outcome variables or did not directly test the relation (2008). Further, while research suggests that within-session habituation of self-reported fear and physiological indices typically occurs, there is limited evidence that this index relates to long-term outcomes (Craske et al., 2008). Finally, although there is some evidence in

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support of between-session habituation as a valid predictor of treatment outcome, other studies have not demonstrated this association. In some studies, the relation between between-session habituation and treatment outcome is not directly tested. Improvement has also been shown to occur in the absence of significant between-session habituation of physiological measures (Craske et al., 2008), suggesting that this index may not be critical to successful exposure treatment. Of note, some studies in clinical samples have directly tested the habituation model of exposure therapy by measuring these three predictors. In a study of adults with panic disorder and agoraphobia completing an abbreviated course of exposure therapy, neither physiological activation nor within-session or between-session reduction of physiological or experiential measures of anxiety was predictive of the treatment outcome, measured as panic disorder symptom severity (Meuret, Seidel, Rosenfield, Hofmann, & Rosenfield, 2012). Similarly, a study of anxious youth found that on the whole, initial fear activation, within-session habituation, and between-session habituation did not predict anxiety-related outcomes at post-treatment or 1-year follow-up, although initial fear activation predicted less anxiety at follow-up among participants without generalized anxiety disorder (Peterman, Carper, & Kendall, 2019). The limited empirical evidence in support of elements of the habituation model, including the roles of initial fear activation, within-session habituation, and between-session habituation, led to the development of a second model of modern-day exposure therapy: the inhibitory learning model.

The inhibitory learning model The inhibitory learning model draws on basic animal and human research in the areas of fear extinction, learning, and memory (Craske et al., 2008, 2014; Craske, Liao, Brown, & Vervliet, 2012). The principles of Pavlovian conditioning dictate that individuals with anxiety disorders have come to fear stimuli in their external or internal environment because of their perceived associations with negative outcomes. These associations, in which the CS is predictive of the US, are known as excitatory associations. One of the goals of exposure therapy is to create new, inhibitory associations as a means of extinguishing fear. Typically, inhibitory associations are between the feared stimulus and the nonoccurrence of the feared outcome, or the occurrence of the feared outcome at a rate or intensity that is lower than expected. The extinguished stimulus therefore has two meanings: excitatory and inhibitory. The prevailing meaning (and the associated response) depends on the current context, which can be either external (e.g., physical environment) or internal (e.g., drug state; Bouton, 2002). Therein lies one of the major challenges

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of successful exposure therapy: strengthening the inhibitory association to the point where it can successfully compete with the excitatory association. One important caveat is that the original excitatory association is not erased from the individual’s memory following extinction (Bouton, 2002). As a consequence, individuals can often experience return of fear. Estimates of return of fear in clinical samples range from 19% to 62% of individuals who have undergone exposure therapy (Craske & Mystkowski, 2006). Forms of return of fear include reinstatement, spontaneous recovery, context renewal, and rapid reacquisition. Vervliet et al. provide an illustrative example of return of fear phenomena (Vervliet, Craske, & Hermans, 2013). Imagine a patient who has undergone successful exposure therapy for panic disorder with agoraphobia, which developed after the patient had a panic attack inside an elevator. Reinstatement can occur when the US is presented alone after extinction (Bouton, 2002). To use the above example, the patient may experience reinstatement of fear after experiencing an out-of-the-blue panic attack. Following the conclusion of extinction, spontaneous recovery of responding occurs when the CS is tested after time has passed (Bouton, 2002). Spontaneous recovery of fear may occur if the patient does not go into elevators for a period of time after the conclusion of exposure therapy. Context renewal refers to the recovery of an extinguished response when the context is changed following extinction (Bouton, 2002). Context renewal of fear might occur if the patient only completed exposures in one location and then attempts to ride an elevator in a novel location. Finally, rapid reacquisition of responding occurs when the CS is again paired with the US following extinction (Bouton, 2002). If the patient were to experience a panic attack inside an elevator after the conclusion of exposure therapy, he or she may experience rapid reacquisition. Proponents of the inhibitory learning model have suggested a number of techniques for enhancing exposure therapy in order to reduce the likelihood of return of fear (Craske et al., 2012, 2014). Some of these techniques apply to all exposures under the inhibitory learning model (common techniques), while others may be relevant for only some exposures in a given course of treatment (specific techniques). Both common and specific techniques are detailed below.

Common techniques One of the major implications of the inhibitory learning model is a shift in focus from habituation to expectancy violation in the design and implementation of exposures. The Rescorla Wagner model (1972) posits that extinction learning occurs when there is a mismatch between

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the expectancy of an event and the absence of its occurrence, that is, when the organism’s expectancy is violated. Expectancy violation is thought to strengthen the inhibitory association, the association that the CS is no longer a predictor of the US. An exposure under this model would be designed to disconfirm the patient’s expectations about the rate or intensity of the feared outcome. Exposures may be designed to last a predetermined length of time (e.g., I will make small talk with a stranger for 5 minutes) based on how long the patient believes it will take for the feared outcome to occur. The therapist can also have the patient rate his or her expectancy of the feared outcome before and after the exposure to further illustrate expectancy violation. Expectancy violation requires the individual to clearly articulate the feared outcome, as well as the predictors (CS) and protectors (conditional inhibitors, including safety objects and behaviors, described in detail subsequently) of the feared outcome prior to the completion of the exposure. It is crucial that the indicators of the feared outcome are objective, given the known attentional and interpretive biases that many individuals with anxiety disorders possess (Mathews & MacLeod, 2005). During in-session exposures, the therapist can act as another judge of these indicators, but this is not possible for between-session exposures. Specificity is critical. For example, an exposure for a patient with public speaking anxiety should explicate the verbal and nonverbal indicators that audience members are judging or rejecting the patient. Alternatively, when the feared outcome is “intolerable distress,” the therapist should work with the patient to clearly operationalize intolerable distress. For example, the patient may fear that they will be unable to function if the feared outcome occurs. An exposure to test this would ask the patient to specify what task he or she fears she will not be able to complete should the feared outcome occur and then incorporate this task into the exposure exercise (e.g., completing an hour’s worth of work, completing household chores). If an exposure is designed to test the association between the CS and nonoccurrence of the US, the therapist should monitor the patient’s level of attention to both throughout the exposure. The goal of these types of exposures is to make the CS and nonoccurrence of the US salient, as research suggests that extinction learning will be directed to the most salient cue (Mackintosh, 1975; Pearce & Hall, 1980). The therapist may notice the patient attempting to distract or otherwise distance himself or herself from the CS, in which case coaching the patient to redirect his or her attention may be necessary. Postexposure consolidation of learning is also critical under the inhibitory learning model. Therapists should guide patients in identifying if the feared outcome occurred or not and discuss the related objective evidence. For exposures in which the feared outcome did not

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occur, the focus of the discussion should be on this new association between the stimulus and the absence of the outcome. For exposures in which the feared outcome did occur, the focus should be on the patient’s ability to tolerate the anxiety associated with the outcome. Oftentimes, patients overestimate the likelihood that the feared outcome will occur or catastrophize the consequences (e.g., I will go crazy or have a heart attack). If relevant, postexposure discussions should highlight these patterns. In a study of children and young adolescents with anxiety disorders, postevent processing of exposure tasks was significantly associated with clinician-rated diagnostic improvements following cognitive behavior therapy (Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013). Under the inhibitory learning model, the principle of variability can be used to guide the design of individual exposures and the overall course of treatment. Research has demonstrated that inhibitory associations are context-dependent, whereas excitatory associations are not context-dependent (Bouton, 2004). Therefore exposures should be conducted across varied external and internal contexts to increase the likelihood that the inhibitory association will generalize to these other contexts. Varying the external context would require exposures to be conducted in different locations, both with and without the therapist present. To ensure that the internal context is varied, the patient can practice exposures at different times of day, for example. Using a sample of students with a fear of spiders, the completion of exposures to videos of spiders in multiple contexts reduced fear renewal when participants were tested in a novel context, demonstrating generalization of extinction learning (Vansteenwegen et al., 2007). Research also suggests that the specific stimuli used in exposures should be varied (Lang & Craske, 2000; Rowe & Craske, 1998). In a nonclinical sample, participants were conditioned to fear a CS and then received extinction either to the CS, a single generalization stimulus (a stimulus similar to the CS), or several generalization stimuli. At test, the group who underwent extinction with several generalization stimuli demonstrated less fear than those who underwent extinction with only one generalization stimulus (Zbozinek & Craske, 2018), demonstrating the importance of variability of stimuli during exposure. For example, if an individual has a specific phobia of spiders, spiders of varying sizes, colors, and shapes should be used. Variability of within-exposure fear levels has also been shown to predict positive outcomes among young adults with contamination anxiety and public speaking anxiety (Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012) and among youths with obsessive compulsive disorder (Kircanski & Peris, 2015), again suggesting that within-session habituation of fear may not be a necessary element of exposure therapy. Rather than using habituation to

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guide the course of treatment, exposures can be conducted in random order from the hierarchy, with varying stimuli, duration, and intensities (Craske et al., 2014).

Specific techniques The elimination of safety signals is a specific technique used in some exposures conducted under the inhibitory learning model. Safety signals can be objects (e.g., medications, cell phone) or people (e.g., therapist, friend or family member). These signals are thought to be detrimental to long-term exposure therapy outcomes because they prevent the patient from learning the inhibitory association (Craske et al., 2014). For example, a patient who takes a benzodiazepine when he or she feels the first physical sensations of anxiety will not have the opportunity to learn that he or she can tolerate the anxiety. Although these safety signals often lessen the fear response during an individual exposure exercise, they ultimately interfere with the long-term goal of inhibitory learning (Craske et al., 2008). Research on the effects of safety signal usage has been mixed, with some studies demonstrating detrimental effects for exposure therapy (Sloan & Telch, 2002), while other studies of individuals with contamination and claustrophobic fears have not found detrimental effects (Deacon, Sy, Lickel, & Nelson, 2010; Rachman, Shafran, Radomsky, & Zysk, 2011; Sy, Dixon, Lickel, Nelson, & Deacon, 2011). In a study of anxious youth, use of safety-seeking behavior during exposure was significantly predictive of poorer outcome (Hedtke, Kendall, & Tiwari, 2009). In order to facilitate the patient remaining in treatment, the elimination of safety signals may be incorporated into the fear hierarchy, in which early exposures allow for the use of safety signals, whereas later exposures do not (Vorstenbosch, Newman, & Antony, 2014). Another technique that can be used in exposures is the inclusion of multiple CS in a single exposure after the patient’s fear to each stimulus has been extinguished independently. This technique is known as deepened extinction (Rescorla, 2006). Deepened extinction requires that both stimuli predict the same outcome. In a nonclinical sample, participants who were presented with single extinction trials followed by compound extinction trials demonstrated significantly less spontaneous recovery of fear responding than participants who were presented with single extinction trials only (Culver, Vervliet, & Craske, 2015). Panic disorder with agoraphobia is particularly amenable to deepened extinction, although exposures targeting other feared outcomes can also make use of this technique. For example, interoceptive exposures that target feared physiological sensations and in vivo exposures that target feared

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situations may be combined after extinguished in isolation (Barlow & Craske, 1994). Another implication of the inhibitory learning model is the inclusion of exposures in which the feared outcome does occur, known as occasional reinforcement. Occasional reinforcement may exert its beneficial effects through expectancy violation or enhanced salience of the CS (Craske et al., 2014). Social anxiety disorder is particularly amenable to this type of exposure, in which feared outcomes such as being embarrassed or rejected are part of daily life. An exposure of this type may involve the patient doing something purposefully embarrassing or silly in front of other people in order to increase the likelihood that they will be judged. For example, the patient may ask for directions to a building that they are standing directly in front of or sing loudly in public. It should be noted, however, that the use of these types of exposures has yet to be examined in the treatment of anxious youth (Peterman, Read, Wei, & Kendall, 2015) and should only be used if deemed ethically appropriate. Further, these exposures should be attempted after building sufficient rapport with the patient and clearly explaining the rationale behind occasional reinforcement to prevent treatment dropout. For some patients, it may be useful to incorporate the use of retrieval cues into treatment. Retrieval cues are introduced during extinction and aid the patient in recalling the inhibitory association following the conclusion of extinction. It is important that retrieval cues do not come to function as safety signals. Retrieval cues are meant to be used solely to recall the inhibitory association, whereas safety signals are associated with the nonoccurrence of the US (Craske et al., 2014). For example, individuals with fear of spiders who were instructed to mentally reinstate the treatment context before encountering a spider in a new context demonstrated less return of fear than those who were not instructed to use mental reinstatement (Mystkowski, Craske, Echiverri, & Labus, 2006). The use of retrieval cues should be introduced later in treatment so that they do not reduce expectancy violation effects. Therefore retrieval cues may be best used as a relapse prevention strategy (Craske et al., 2014).

Exposure therapy for children and adolescents Exposure therapy is an evidence-based treatment for children and adolescents with anxiety disorders, including generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, specific phobias, panic disorder, and obsessive compulsive disorder (Peterman et al., 2015). There are, however, several important considerations to be

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made in conducting exposure therapy with anxious youth, given their developmental stage (Kingery et al., 2006). We focus here on considerations that relate to the inhibitory learning model of exposure therapy. Exposures conducted using an inhibitory learning approach rely on expectancy violation rather than habituation. Expectancy violation requires the identification of the feared outcome, the predictors, and protectors of that outcome, as well as the objective indicators that the outcome did or did not occur. Depending on the age of the patient, this may prove difficult. It may be that the child is unable to articulate what outcome he or she is afraid of, or if able to do so, unable to explicate truly objective markers of the outcome. Indeed, the goal of many exposures with children may be less focused on expectancy violation and more on tolerance of distress. In these cases, the new association to be learned is the ability to tolerate the fear or anxiety in the presence of the feared stimulus. Beyond mere tolerance, an additional goal for patients is to learn that they can function even when experiencing anxiety (Abramowitz, 2013). An exposure may be designed in which the patient attempts to complete a predetermined task after becoming anxious, such as carrying on a conversation with a stranger or completing a homework assignment. The goal of this type of exposure is to illustrate that the patient can function in spite of his or her anxiety. It has been suggested that therapists present exposure as a technique for coping with anxiety, with an emphasis on the goals of improved approach behavior and daily functioning (Peterman et al., 2015). The Rescorla Wagner and inhibitory learning models dictate that exposures that center on maximal expectancy violation will be most effective in creating the inhibitory association. Other cognitive behavior therapy interventions may serve to reduce the patient’s expectancy of the feared outcome (Craske et al., 2014). For example, cognitive restructuring techniques in which a patient decatastrophizes an outcome by examining the realistic likelihood of its occurrence would negate the opportunity for maximal expectancy violation. Restructuring and coping skills may also be used as safety behaviors or as a means of distraction, undermining the effectiveness of exposures (Peterman et al., 2015). For these reasons, cognitive behavior therapy under this model would dictate that exposures be conducted prior to other interventions. In a review of cognitive behavior therapy for panic disorder and agoraphobia, the authors reported that evidence for the augmenting effect of cognitive and biobehavioral coping skills on exposure was inconclusive (Meuret, Wolitzky-Taylor, Twohig, & Craske, 2012). One of the most widely studied and disseminated treatments for childhood anxiety, the Coping Cat Program, teaches anxiety management strategies prior to exposure (Kendall & Hedtke, 2006). It may be the case that when treating anxious youth, it is necessary to first teach other anxiety

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management strategies so that the patient will agree to engage in the exposure portion of treatment. Another major consideration is the involvement of parents and family members in the design and execution of exposures. As noted previously, laboratory research suggests that the original excitatory association is context-independent, whereas the inhibitory association is context-dependent (Bouton, 2004). Practically, this means that exposures should be conducted in a variety of external and internal contexts so that the inhibitory association can successfully generalize. Betweensession exposure practice is therefore key to successful treatment and depending on the age of the child, parents may play an important role in ensuring that the patient completes exposures outside of sessions. Indeed, parents may sometimes be integral to the exposures themselves, as in the case of separation anxiety disorder, or provide necessary logistical support (e.g., transportation, facilitating opportunities for social interaction). One theoretical model of exposure with anxious youth proposes that long-term outcomes are dependent on transfer of control from therapist to parent to patient (Silverman, Ginsburg, & Kurtines, 1995). When deemed safe and appropriate, however, exposures should also be conducted without parental involvement as the parent may serve as a contextual stimulus. As with all elements of exposure, the therapist should take the patient’s developmental stage into account. For example, adolescents may require less involvement from parents in the completion of exposures and parental overinvolvement may deter the patient from completing exposures or threaten the therapeutic alliance. It is worth noting that parental involvement in exposure therapy can pose challenges. Research suggests that among youth with anxiety disorders, up to 80% of their parents also have an anxiety disorder (Ginsburg & Schlossberg, 2002). Parents may reinforce maladaptive coping behavior and avoidance (Connolly and Bernstein, 2007). Factors including parental cognitions, parental modeling of anxious behavior, and passive parenting style have all been associated with child anxiety (Bo¨gels & Brechman-Toussaint, 2006). In the context of exposure, parents may have either inaccurate or unrealistic expectations for what their child is capable of given his or her developmental stage (Kingery et al., 2006). In particular, repeated noncompletion of between-session exposure practice may be indicative that a parent is reinforcing the patient’s avoidance. Some parents may have difficulty watching their child complete exposures in which he or she is in distress, even if the level of anxiety the child is experiencing is developmentally appropriate. Providing parents with thorough psychoeducation about the rationale underlying exposure therapy at the beginning of treatment is crucial and it may be necessary to revisit the topic as obstacles arise.

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Conclusion Exposure therapy is an empirically supported treatment for children and adolescents with a range of anxiety disorders. A therapist’s understanding of the theory underlying exposure therapy is thought to be critical to the treatment’s success (Abramowitz, 2013). To this end, this chapter provided an overview of the history of exposure therapy and related theory. First, we reviewed Wolpe’s systematic desensitization procedure and the concept of reciprocal inhibition, thought to be the mechanism of change in this treatment. Second, we reviewed the habituation model of exposure therapy. We then reviewed the inhibitory learning model of exposure therapy, which is based on recent advances in learning and memory research, and some implications of this model for conducting exposure therapy. Finally, we discussed some of the necessary developmental considerations when conducting exposure therapy using the inhibitory learning model.

Acknowledgment The authors wish to thank Dr. Michelle Rozenman for her valuable input on considerations for conducting exposure therapy with anxious youth.

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basic processes to clinical implications (pp. 217 233). Washington DC: American Psychiatric Association. Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10 23. Culver, N. C., Stoyanova, M., & Craske, M. G. (2012). Emotional variability and sustained arousal during exposure. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 787 793. Culver, N. C., Vervliet, B., & Craske, M. G. (2015). Compound extinction: Using the Rescorla-Wagner model to maximize exposure therapy effects for anxiety disorders. Clinical Psychological Science, 3(3), 335 348. Davison, G. C. (1968). Systematic desensitization as a counterconditioning process. Journal of Abnormal Psychology, 73(2), 91 99. Dawson, R. W., & McMurray, N. E. (1978). Desensitization without hierarchical presentation and concomitant relaxation. Australian Journal of Psychology, 30(2), 119 132. Deacon, B. J., Sy, J., Lickel, J. J., & Nelson, E. O. (2010). Does the judicious use of safety behaviors improve the efficacy and acceptability of exposure therapy for claustrophobic fear? Journal of Behavior Therapy and Experimental Psychiatry, 41, 71 80. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York: Oxford University Press. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20 35. Foa, E. B., & McNally, R. J. (1996). Mechanisms of change in exposure therapy. In R. M. Rapee (Ed.), Current controversies in anxiety disorders (pp. 329 343). New York: Guilford Press. Gillan, P., & Rachman, S. (1974). An experimental investigation of desensitization in phobic patients. British Journal of Psychiatry, 124, 392 401. Ginsburg, G. S., & Schlossberg, M. C. (2002). Family-based treatment of anxiety disorders. International Review of Psychiatry, 14, 143 154. Hedtke, K. A., Kendall, P. C., & Tiwari, S. (2009). Safety-seeking and coping behavior during exposure tasks with anxious youth. Journal of Clinical Child & Adolescent Psychology, 38(1), 1 15. Higa-McMillan, C. K., Francis, S. E., Rith-Najarian, L., & Chorpita, B. F. (2016). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 45(2), 91 113. Jacobson, E. (1939). Variation of blood pressure with skeletal muscle tension and relaxation. Annals of Internal Medicine, 12(8), 1194 1212. Jones, M. C. (1924a). A laboratory study of fear: The case of Peter. Pedagogical Seminary, 31, 308 315. Jones, M. C. (1924b). The elimination of children’s fears. Journal of Experimental Psychology, 7, 382 390. Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66(1), 19 36. Kazdin, A. E., & Wilcoxon, L. A. (1976). Systematic desensitization and nonspecific treatment effects: A methodological evaluation. Psychological Bulletin, 83(5), 729 758. Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook. Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12, 136 150.

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Kingery, J. N., Roblek, T. L., Suveg, C., Grover, R. L., Sherrill, J. T., & Bergman, R. L. (2006). They’re not just “little adults”: Developmental considerations for implementing cognitive-behavioral therapy with anxious youths. Journal of Cognitive Psychotherapy: An International Quarterly, 20(3), 263 273. Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 745 751. Kircanski, K., & Peris, T. S. (2015). Exposure and response prevention process predicts treatment outcome in youth with OCD. Journal of Child Abnormal Psychology, 43, 543 552. Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to reduce return of fear: A replication. Behaviour Research and Therapy, 38, 1 12. Mackintosh, N. J. (1975). A theory of attention: Variations in the associability of stimuli with reinforcement. Psychological Review, 82(4), 276 298. Mathews, A. (1971). Psychophysiological approaches to the investigation of desensitization and related procedures. Psychological Bulletin, 76(2), 73 91. Mathews, A. (1978). Fear-reduction research and clinical phobias. Psychological Bulletin, 85 (2), 390 404. Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology, 1, 167 195. Meuret, A. E., Seidel, A., Rosenfield, B., Hofmann, S. G., & Rosenfield, D. (2012). Does fear reactivity during exposure predict panic symptom reduction? Journal of Consulting and Clinical Psychology, 80(5), 773 785. Meuret, A. E., Wolitzky-Taylor, K. B., Twohig, M. P., & Craske, M. G. (2012). Coping skills and exposure therapy in panic disorder and agoraphobia: Latest advances and future directions. Behavior Therapy, 43, 271 284. Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006). Mental reinstatement of context and return of fear in spider-fearful participants. Behavior Therapy, 37, 49 60. Pearce, J. M., & Hall, G. (1980). A model for Pavlovian learning: Variations in the effectiveness of conditioned but not of unconditioned stimuli. Psychological Review, 87(6), 532 552. Peris, T. S., Caporino, N. E., O’Rourke, S., Kendall, P. C., Walkup, J. T., Albano, A. M., . . . Compton, S. N. (2017). Therapist-reported features of exposure tasks that predict clinical treatment outcomes for youth with anxiety. Journal of the American Academy of Child & Adolescent Psychiatry, 56(12), 1043 1052. Peris, T. S., Compton, S. N., Kendall, P. C., Birmaher, B., Sherill, J., March, J., . . . Piacentini, J. (2015). Trajectories of change in youth anxiety during cognitive behavior therapy. Journal of Consulting and Clinical Psychology, 83(2), 239 252. Peterman, J. S., Carper, M. M., & Kendall, P. C. (2019). Testing the habituation-based model of exposure therapy for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 48(1), S34 S44. Available from https://doi.org/10.1080/ 15374416.2016.1163707. Peterman, J. S., Read, K. L., Wei, C., & Kendall, P. C. (2015). The art of exposure: Putting science into practice. Cognitive and Behavioral Practice, 22, 379 392. Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy, 18, 51 60. Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011). Reducing contamination by exposure plus safety behaviour. Journal of Behavior Therapy and Experimental Psychiatry, 42, 397 404. Rescorla, R. A. (2006). Deepened extinction from compound stimulus presentation. Journal of Experimental Psychology: Animal Behavior Processes, 32(2), 135 144.

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Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. H. Black, & W. F. Prokasy (Eds.), Classical conditioning II: Current research and theory (pp. 64 99). New York: Appleton-Century-Crofts. Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on fear reduction and return of fear. Behaviour Research and Therapy, 36, 719 734. Silverman, L. H., Frank, S. G., & Dachinger, P. (1974). A psychoanalytic reinterpretation of the effectiveness of systematic desensitization: Experimental data bearing on role of merging fantasies. Journal of Abnormal Psychology, 83(3), 313 318. Silverman, W. K., Ginsburg, G. S., & Kurtines, W. M. (1995). Clinical issues in treating children with anxiety and phobic disorders. Cognitive and Behavioral Practice, 2, 93 117. Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behavior Research and Therapy, 40, 235 251. Sy, J. T., Dixon, L. J., Lickel, J. J., Nelson, E. A., & Deacon, B. J. (2011). Failure to replicate the deleterious effects of safety behaviors in exposure therapy. Behaviour Research and Therapy, 49(5), 305 314. Tiwari, S., Kendall, P. C., Hoff, A. L., Harrison, J. P., & Fizur, P. (2013). Characteristics of exposure sessions as predictors of treatment response in anxious youth. Journal of Clinical Child & Adolescent Psychology, 42(1), 34 43. Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., Van den Bergh, O., & Hermans, D. (2007). The repeated confrontation with videotapes of spiders in multiple contexts attenuates renewal of fear in spider-anxious students. Behaviour Research and Therapy, 45(6), 1169 1179. Vervliet, B., Craske, M. G., & Hermans, D. (2013). Fear extinction and relapse: State of the art. Annual Review of Clinical Psychology, 9, 215 248. Voort, J. L. V., Svecova, J., Jacobsen, A. B., & Whiteside, S. P. (2010). A retrospective examination of the similarity between clinical practice and manualized treatment for childhood anxiety disorders. Cognitive and Behavioral Practice, 17, 322 328. Vorstenbosch, V., Newman, L., & Antony, M. M. (2014). Exposure techniques. In S. G. Hofmann (Ed.), The Wiley handbook of cognitive behavioral therapy (1st ed., pp. 45 65). Hoboken, NJ: Wiley-Blackwell. Waters, W. F., McDonald, D. G., & Koresko, R. J. (1972). Psychophysiological responses during analogue systematic desensitization and non-relaxation control procedures. Behaviour Research & Therapy, 10, 381 393. Wolpe, J. (1952). Experimental neuroses as learned behavior. British Journal of Psychiatry, 43 (4), 243 268. Wolpe, J. (1954). Reciprocal inhibition as the main basis of psychotherapeutic effects. Archives of Neurology and Psychiatry, 72, 205 226. Wolpe, J. (1961). The systematic desensitization treatment of neuroses. Journal of Nervous and Mental Disease, 132(3), 189 203. Wolpe, J. (1968). Psychotherapy by reciprocal inhibition. Conditional Reflex: A Pavlovian Journal of Research & Therapy, 3(4), 234 240. Wolpe, J. (1973). The practice of behavior therapy. London, UK: Pergamon Press. Zbozinek, T. D., & Craske, M. G. (2018). Pavlovian extinction of fear with the original conditional stimulus, a generalization stimulus, or multiple generalization stimuli. Behavior Research and Therapy, 107, 64 75.

Further reading Rachman, S. (1959). The treatment of anxiety and phobic reactions by systematic desensitization psychotherapy. Journal of Abnormal and Social Psychology, 58(2), 259 263.

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C H A P T E R

2 Efficacy of exposure-based cognitive behavioral therapy for youth anxiety and obsessive-compulsive disorder Katherine C. Bergez1, Ana C. Ramirez1, Stacey C. Grebe1, Mayra I. Perez1, Andres G. Viana2, Eric A. Storch1 and Sophie C. Schneider1 1

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States, 2Department of Psychology, University of Houston, Houston, TX, United States

Introduction Exposure-based cognitive behavioral therapy (CBT) is a first-line treatment for anxiety disorders and obsessive-compulsive disorder (OCD) in pediatric populations (Connolly, Bernstein, & Work Group on Quality Issues, 2007; Geller, March, & AACAP Committee on Quality ¨ st, Riise, Wergeland, Hansen, & Kvale, 2016; Wang et al., Issues, 2012; O 2017). This chapter provides an overview of the strength of the evidence base for exposure-focused CBT and examples of key interventions. It also reviews delivery format variations and clinical considerations that may impact treatment selection or outcomes. The chapter first reviews the efficacy of anxiety-focused CBT interventions, followed by OCD-specific interventions (e.g., exposure/response prevention).

Exposure Therapy for Children with Anxiety and OCD DOI: https://doi.org/10.1016/B978-0-12-815915-6.00002-0

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Copyright © 2020 Elsevier Inc. All rights reserved.

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Overview of cognitive behavioral therapy for youth anxiety disorders The most comprehensive meta-analysis to date of youth anxiety treatment (115 studies, including 88 CBT studies with 6978 youth) supported CBT as an efficacious treatment for anxiety disorders in children and adolescents (Wang et al., 2017). Further, CBT was associated with fewer adverse events and lower attrition rates when compared to medication and placebo interventions, supporting the acceptability and tolerability of treatment. Other meta-analyses have highlighted the central importance of exposure within CBT (Ale, McCarthy, Rothschild, & Whiteside, 2015), and demonstrated that higher doses of exposure are associated with improved treatment outcomes for youth with anxiety (Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013).

Examples of key interventions for youth anxiety disorders The Coping Cat program Coping Cat is a manualized individual CBT protocol for youths aged 7 13 years. The protocol is comprised of 16 individual therapist-led sessions, and includes a therapist manual and workbooks for parent and child (Kendall & Hedtke, 2006a, 2006b). Several adaptations of this program have been developed, including an eight-session brief Coping Cat version (Crawley et al., 2013), Kiddie Cat for children between the ages of 4 and 7 years (Hughes, Hedtke, Flannery-Schroeder, & Kendall, 2005), C.A.T Project Manual for youths ages 13 18 years (Kendall, 2002), and the Camp Cope-A-Lot online intervention (Khanna & Kendall, 2010). Coping Cat’s effectiveness has been evaluated by multiple trials and in different therapeutic settings, showing it to be an effective anxiety reduction intervention with good maintenance effects (Kendall, 1994; Villabø, Narayanan, Compton, Kendall, & Neumer, 2018), and superiority over a non-CBT supportive child-centered therapy intervention (71% response vs 56%; Silk et al., 2018). Most notably, Coping Cat and the associated adolescent version were used in the landmark Child/ Adolescent Anxiety Multimodal Study (CAMS), which compared CBT, sertraline, combined treatment (CBT 1 sertraline), and placebo (Walkup et al., 2008). Combined treatment was found to be the most effective (81% response rate), followed by CBT or sertraline alone (60% and 55% response), though all were more effective than placebo (24% response). Secondary analysis of the CAMS study indicated that treatment outcomes were generally maintained at 36 weeks (Piacentini et al., 2014). Across treatment conditions, poorer treatment outcomes were predicted

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by more severe baseline anxiety, higher caregiver strain, and a primary diagnosis of social anxiety disorder (Compton et al., 2014). Poorer outcomes in the CBT condition were found for youth with comorbid attention-deficit hyperactivity disorder (ADHD), but not oppositional defiant disorder (Halldorsdottir et al., 2015). Importantly, Taylor et al. (2018) found that combined CBT and medication treatment may be needed for anxiety remission in youth with severe anxiety.

Cool Kids The Cool Kids program is a manualized CBT protocol for the treatment of anxiety disorders in children and adolescents aged 7 18 years. Treatment consists of 10 sessions delivered over 12 weeks in group or individual format, and includes a therapist manual (Rapee, Lyneham, et al., 2006) and workbooks for parent and child (Lyneham, Wignall, & Rapee, 2012). Cool Kids has been adapted into several formats, including Cool Teens for 13- to 18-year-olds (Cunningham et al., 2006), Cool Kids School Version (Mifsud & Rapee, 2005), Cool Little Kids Online (Morgan, Rapee, & Bayer, 2016), Helping Your Anxious Child self-help or therapist-supported bibliotherapy (Lyneham & Rapee, 2006; Rapee, Wignall, Spence, Lyneham, & Cobham, 2008), and delivered via videoconferencing (McLellan, Andrijic, Davies, Lyneham, & Rapee, 2017). The Cool Kids program has been well validated and shown to be efficacious in the reduction of anxiety symptoms for children and adolescents (Arendt, Thastum, & Hougaard, 2016; Rapee, 2000; Rapee, Abbott, & Lyneham, 2006). Research has also supported using a stepped care model, where families begin with bibliotherapy and minimal therapist support, then progress to standard individual therapy if required (Rapee et al., 2017). This stepped care format had similar efficacy to standard individual Cool Kids, while requiring less therapist time and incurring lower societal costs (Chatterton et al., 2019). Good treatment outcomes have also been found for effectiveness studies in outpatient psychiatric clinics (Djurhuus & Bikic, 2019).

Delivery format considerations for anxiety disorder treatment Remote treatment Teletherapy involves any type of psychological service delivered by using telecommunication technologies, such as internet, videoconferencing, and telephone-based delivery (American Psychological Association, 2013). Teletherapy has the potential to significantly increase access to treatment, especially for individuals with limited access to CBT in their

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local area. Evidence supports the delivery of CBT across multiple teletherapy formats, such as Camp Cope-A-Lot (Khanna & Kendall, 2010), Cool Kids Outreach Program (McLellan et al., 2017), and Cool Little Kids Online (Morgan et al., 2016). Effect sizes in teletherapy have been found to be comparable to those of face-to-face format (Ebert et al., 2015). Meta-analyses of internet-based interventions support the potential utility of this format (Vigerland, Lenhard, et al., 2016), however, further work is needed to increase the uptake of such programs in routine clinical practice (Hill et al., 2018). Another promising format for remote treatment is self-help treatments, where families work through a structured CBT program at home. These may involve some level of therapist support or may be purely self-guided. Self-help treatments with various levels of therapist support are an efficacious and convenient treatment option for anxiety in children and adolescents (Lyneham & Rapee, 2006; Rapee, Abbott, et al., 2006), though treatment effects may be smaller than standard treatment approaches (Vigerland, Ljo´tsson, et al., 2016).

Treatment intensity Results indicate little difference in overall effect size between shorter duration (e.g., up to 10 sessions) and longer duration (e.g., more than 10 sessions) CBT (Ishikawa, Okajima, Matsuoka, & Sakano, 2007). Meta-analytic results indicate that treatments with a reduced number of sessions and/or more frequent sessions are successful in treating childhood anxiety disorders and have a lower attrition rate than stan¨ st & Ollendick, 2017). Additionally, dard CBT (2% compared to 6%; O treatment effects were maintained at 1-year follow-up, and these interventions performed better than standard CBT. An intensive five-day outpatient CBT model for youth anxiety produced moderate to large effects on anxiety reduction, and increased access for families in diverse geographic locations (Whiteside, Dammann, Tiede, Biggs, & Jensen, 2018). Intensive treatment formats appear to be an effective option that may increase access for families with difficulty attending sessions.

Group or individual therapy CBT produces similar results regardless of treatment delivery format. No difference was found between group, individual, and guided selfhelp delivery formats in specialized child anxiety treatment participants (Hudson et al., 2015; McKinnon et al., 2018), and no difference was found between group and individual treatment in a community

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health setting (Villabø et al., 2018). This indicates that therapists can provide CBT in a variety of formats without compromising treatment effectiveness.

Impact of clinical characteristics on anxiety disorder treatment Family factors The majority of parents of youth with anxiety disorders perform some form of symptom accommodation daily, such as assisting their child in escaping and avoiding anxiety-provoking situations and feared stimuli (La Buissonnie`re-Ariza et al., 2018; Lebowitz et al., 2013). Reductions in family accommodation during treatment are associated with improvement in child anxiety severity and functional impairment (Kagan, Peterman, Carper, & Kendall, 2016; La Buissonnie`re-Ariza et al., 2018). Additionally, higher levels of parental psychopathology are associated with poorer response to treatment (Hudson et al., 2015), and children with nonanxious parents are more likely to be diagnosis free following treatment compared to children with anxious parents (Hudson et al., 2013). The association between parental psychopathology and child anxiety may be related to caregiver strain and family functioning (Schleider et al., 2015), highlighting the important role of parental and family factors in the treatment of youth anxiety.

Social anxiety disorder Although social anxiety disorder can be treated effectively using general CBT protocols, primary social anxiety disorder is associated with less reduction in disorder severity following CBT (Taylor et al., 2018) and lower rates of disorder remission compared to other primary anxiety disorders (Hudson et al., 2015). This has also been demonstrated in CBT delivered in community settings, where primary social anxiety disorder is associated with poorer long-term recovery (Kodal et al., 2018). CBT protocols have been developed to focus on social anxiety disorder, and a metaanalysis of such interventions found a large effect of treatment on anxiety symptoms (Scaini, Belotti, Ogliari, & Battaglia, 2016). Outcomes were enhanced for studies with longer treatment duration and with social skills training components (for a review, see Mesa, Le, & Beidel, 2015). However, a trial of therapist-supported online CBT for social anxiety disorder found that generic CBT and social anxiety-specific CBT performed similarly in reducing social anxiety, though most participants failed to achieve disorder remission (Spence, Donovan, March, Kenardy, & Hearn, 2017). Further research is clearly needed to identify modifications to CBT

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that can enhance outcomes for social anxiety disorder. Additionally, youth with social anxiety disorder may particularly benefit from augmentation of CBT with medication (Compton et al., 2014).

Specific phobias One session treatment for specific phobias is an exposure-focused protocol that takes place in a single 3-hour session, focusing on massed exposure to the phobic object or situation (Nielsen, Andreasen, & Thastum, ¨ st, 1989). One session treatment has demonstrated effectiveness for 2016; O the treatment of specific phobias in children and adolescents; approximately 50% of patients no longer meet diagnostic criteria for specific phobias posttreatment, and treatment gains are maintained at six-month follow up (Nielsen et al., 2016; Ollendick et al., 2015). The benefits of one session treatment are also found in youth who have comorbid anxiety disorders (Ryan, Strege, Oar, & Ollendick, 2017). Interestingly, treatment response rates appear to be better for adolescents compared to younger children (Nielsen et al., 2016; Ollendick et al., 2015). One session treatment may be particularly beneficial where specific phobias are a primary concern, and where families prefer not to attend multiple treatment sessions.

Comorbid disorders Although evidence regarding the impact of comorbidity on treatment response is mixed, the presence of comorbid disorders has been associated with poorer treatment response across different studies (Knight, McLellan, Jones, & Hudson, 2014). The largest single study involved pooled data from multiple treatment groups found that depressive and externalizing disorders were both associated with poorer treatment outcomes (Hudson et al., 2015). ADHD was associated with poorer treatment response to CBT in the CAMS study (Halldorsdottir et al., 2015), but not in a large pooled sample of Cool Kids participants (Gould, Porter, Lyneham, & Hudson, 2018).

Overview of cognitive behavioral therapy for youth obsessive compulsive disorder CBT is a first-line treatment for OCD in pediatric populations ¨ st et al., 2016). (Freeman, Garcia, et al., 2014; McGuire et al., 2015; O A meta-analysis of 34 randomized controlled trials (24 CBT, 1195 youth included) found that CBT has a moderate effect on OCD symptom ¨ st et al., 2016). CBT alone resulted in a 70% treatment reduction (O

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response rate, which was similar to the response rate for combined CBT and medication (66%), and significantly higher than those for medica¨ st et al., 2016). Results indicated tion, placebo, and waitlist control (O that OCD symptom severity moderated treatment effects, such that higher baseline symptom severity resulted in a larger effect of CBT on symptom reduction. The meta-analysis found that CBT is the most effective first-line treatment for youth with OCD.

Examples of key interventions for obsessive-compulsive disorder The Pediatric OCD Treatment Study The Pediatric OCD Treatment Study (POTS) study was a landmark randomized controlled trial investigating CBT and pharmacological treatment for OCD among youths aged 7 17 years (Pots Team, 2004). Youths were randomized to placebo, CBT, sertraline, or combined treatment (CBT 1 sertraline). Manualized CBT was based on the seminal manual for the treatment of OCD in youth published by March and Mulle (1998). This widely cited manual has formed the basis for CBT manuals across multiple OCD studies (Franklin et al., 2011; Pots Team, 2004; Storch et al., 2013). The POTS CBT protocol is comprised of 14 one-hour visits over the span of 12 weeks. Results revealed that CBT alone or combined with sertraline was most effective in the reduction of OCD symptoms. CBT alone resulted in a 39.3% remission rate, which did not differ significantly from that of combined treatment (53.6%). However, a large effect size was found for CBT alone, which was significantly higher than that found for medication alone. Poorer treatment outcome was associated with higher baseline OCD severity, higher OCD-related functional impairment, poorer insight, higher levels of comorbid externalizing symptoms, increased family accommodation, and positive family history of OCD (Garcia et al., 2010).

The Pediatric OCD Treatment Study Junior Following the original POTS trial, POTS Jr. was developed to investigate the relative efficacy of CBT compared to family-based relaxation treatment in children aged 5 8 years (Freeman, Sapyta, et al., 2014). The treatment protocols were adapted to describe relevant information to children at a younger developmental level, and to provide more parent involvement in sessions. The POTS Jr. CBT manual is comprised of 12 sessions delivered over 12 weeks. Results revealed that CBT was superior to the control condition; at posttreatment, 72% of CBT participants responded

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to treatment, compared to 41% in the active control group. Response rates and overall treatment effect size were consistent with similar treatments for older children and adolescents. POTS Jr. provides confidence to therapists that CBT can be effectively delivered to young children with OCD using appropriate developmental adaptations.

Nordic Long-Term OCD Treatment Study The Nordic Long-Term OCD Treatment Study (NordLOTS) investigated the efficacy of a manualized exposure-based CBT protocol for the treatment of youth OCD in community mental health clinics in Denmark, Norway, and Sweden (Torp et al., 2015). The treatment was adapted based on extant work (March, Mulle, Foa, & Kozak, 2000), and was comprised of weekly 75-minute sessions over the course of 14 weeks, with parents attending 6 of the sessions. Of the 89% of participants who completed the full dose of treatment, 73% of participants were classified as treatment responders and displayed a significant reduction in OCD symptoms (65% of the full sample; Torp et al., 2015). Among treatment responders, 92% maintained treatment response at 1-year follow up (60% of the full sample; Højgaard, Hybel, et al., 2017). NordLOTS indicates that good treatment outcomes can be obtained in community health contexts by nonexpert OCD providers with ongoing consultation.

Delivery format considerations for obsessive compulsive disorder treatment Remote treatment Remote treatment modalities reduce barriers for families in accessing care and can improve the efficiency of dissemination (Abramowitz, Blakey, Reuman, & Buchholz, 2018). These treatments have shown promising results in the reduction of OCD symptoms in pediatric populations, can vary with respect to intensity (e.g., ranging from selfdirected content, minimal therapist support, to therapist contact paralleling face-to-face sessions), and can be delivered through different modalities (e.g., internet, telehealth, and smartphone applications; Abramowitz et al., 2018). A meta-analysis of youth and adult studies found that clinician-guided remote therapy produced larger effect sizes than self-guided remote therapy, and that among the small number of available studies, remote therapy demonstrated similar efficacy to face-to-face treatments (Wootton, 2016). Storch et al. (2011) adapted the POTS (2004) protocol for delivery via videoconferencing with emailed or scanned handouts and homework, and OCD symptoms were reduced

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by over 50% after completion of treatment. The internet-delivered CBT protocol OCD? Not Me! for youth aged 12 18 has shown encouraging results in self-reported OCD symptom reduction (Rees, Anderson, Kane, & Finlay-Jones, 2016). Further, the Mayo Clinic Anxiety Coach iOS app has shown promise in reducing OCD symptomatology with content including monitoring of the frequency of anxiety/OCD symptoms, psychoeducation, and guided instruction through exposure activities (Whiteside, Ale, Vickers Douglas, Tiede, & Dammann, 2014). Remote treatment modalities thus appear to have promise as a treatment option, especially for those who have difficulty accessing traditional CBT.

Intensive treatments Intensive therapies are typically recommended for children with severe OCD symptomology, complex clinical presentations, treatment resistance, or those requiring quick improvement (Jo´nsson, Kristensen, & Arendt, 2015). An intensive five-day outpatient CBT model for youth anxiety and OCD has demonstrated promising results, with moderate to large effects on anxiety reduction according to both children and parents (Whiteside et al., 2018). Other intensive treatment approaches can include more frequent therapy visits and longer durations of sessions. Storch et al. (2007) found higher rates of treatment response when 14 sessions of CBT were delivered daily compared to weekly, though outcomes were similar at 3-month follow up. Intensive treatments can also be delivered in residential programs, often including medication management (Leonard et al., 2016; Højgaard et al., 2019; Whiteside et al., 2018). For example, in a study of adolescents receiving multimodal residential treatment (CBT combined with medication management for most participants), approximately 26.5 hours of CBT was received per week, and treatment response was found in 79% of these participants (Leonard et al., 2016). Another residential study of youth who had failed to respond to previous CBT for OCD found that 55% responded to treatment (Dowling et al., 2016), supporting the use of residential treatment in those with complex clinical presentations or who have failed to respond to previous CBT trials.

Impact of clinical characteristics on obsessive compulsive disorder treatment Family factors Family accommodation is very common in youth OCD, and is associated with greater symptom severity and functional impairment

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(Wu, Lewin, Murphy, Geffken, & Storch, 2014). Additionally, increased family accommodation is associated with poorer treatment response (Freeman, Sapyta, et al., 2014; Garcia et al., 2010). Several factors have been found to be predictive of family accommodation, including parental psychopathology, family history of OCD, and severity of child OCD and oppositional behaviors (Flessner et al., 2011). Further, family history of OCD has been shown to moderate treatment outcomes such that those with a positive family history may require combined treatment instead of CBT alone (Garcia et al., 2010). Therapists may benefit from considering family factors, including family accommodation and parental anxiety, when implementing CBT for youth with OCD.

Comorbid disorders Youth with comorbid psychiatric diagnoses may display less improvement and require more intensive treatment than those with OCD alone due to greater symptom complexity (Leonard et al., 2016). Comorbid externalizing symptoms have been associated with poorer treatment outcomes (Garcia et al., 2010). Meta-analysis indicates that the percentage of participants with chronic tic disorders is positively associated with higher CBT effect sizes (McGuire et al., 2015), indicating that tic-related OCD is associated with greater response to CBT. In the NordLOTS study, tic-related OCD was found in 30% of participants, and though it was associated with differences in clinical features, tic-related OCD was not associated with treatment outcome (Højgaard, Skarphedinsson, et al., 2017).

Conclusion Exposure-based CBT is an effective treatment for anxiety disorders and OCD in youth. Multiple treatment protocols are available with established efficacy for youth anxiety and OCD, and a variety of delivery format adaptations are available to suit the needs of therapists and families. Adaptations such as brief intensive treatments, remote delivery of CBT, and therapist-guided self-help have great potential for increasing access to care. Further research is needed regarding predictors of treatment outcome and how to maximize efficiency of care. Overall, there is a strong evidence base for exposure¨ st et al., 2016; Wang et al., based CBT in youth anxiety and OCD (O 2017).

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therapy alone or combined with sertraline in the treatment of pediatric obsessive compulsive disorder. Behaviour Research and Therapy, 51(12), 823 829. Available from https://doi.org/10.1016/j.brat.2013.09.007. Storch, E. A., Caporino, N. E., Morgan, J. R., Lewin, A. B., Rojas, A., Brauer, L., . . . Murphy, T. K. (2011). Preliminary investigation of web-camera delivered cognitivebehavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Research, 189(3), 407 412. Available from https://doi.org/10.1016/j.psychres.2011.05.047. Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., . . . Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child and Adolescent Psychiatry, 46(4), 469 478. Available from https://doi.org/10.1097/chi.0b013e31803062e7. Taylor, J. H., Lebowitz, E. R., Jakubovski, E., Coughlin, C. G., Silverman, W. K., & Bloch, M. H. (2018). Monotherapy insufficient in severe anxiety? Predictors and moderators in the child/ adolescent anxiety multimodal study. Journal of Clinical Child and Adolescent Psychology, 47 (2), 266 281. Available from https://doi.org/10.1080/15374416.2017.1371028. Tiwari, S., Kendall, P. C., Hoff, A. L., Harrison, J. P., & Fizur, P. (2013). Characteristics of exposure sessions as predictors of treatment response in anxious youth. Journal of Clinical Child and Adolescent Psychology, 42(1), 34 43. Available from https://doi.org/ 10.1080/15374416.2012.738454. Torp, N. C., Dahl, K., Skarphedinsson, G., Thomsen, P. H., Valderhaug, R., Weidle, B., . . . Ivarsson, T. (2015). Effectiveness of cognitive behavior treatment for pediatric obsessive-compulsive disorder: Acute outcomes from the Nordic long-term OCD treatment study (NordLOTS). Behaviour Research and Therapy, 64, 15 23. Available from https://doi.org/10.1016/j.brat.2014.11.005. Vigerland, S., Lenhard, F., Bonnert, M., Lalouni, M., Hedman, E., Ahlen, J., . . . Ljo´tsson, B. (2016). Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clinical Psychology Review, 50, 1 10. Available from https://doi.org/10.1016/j.cpr.2016.09.005. ¨ st, L.-G., Andersson, G., & Serlachius, E. (2016). Vigerland, S., Ljo´tsson, B., Thulin, U., O Internet-delivered cognitive behavioural therapy for children with anxiety disorders: A randomised controlled trial. Behaviour Research and Therapy, 76, 47 56. Available from https://doi.org/10.1016/j.brat.2015.11.006. Villabø, M. A., Narayanan, M., Compton, S. N., Kendall, P. C., & Neumer, S.-P. (2018). Cognitive behavioral therapy for youth anxiety: An effectiveness evaluation in community practice. Journal of Consulting and Clinical Psychology, 86(9), 751 764. Available from https://doi.org/10.1037/ccp0000326. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., . . . Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753 2766. Available from https://doi.org/10.1056/NEJMoa0804633. Wang, Z., Whiteside, S. P. H., Sim, L., Farah, W., Morrow, A. S., Alsawas, M., . . . Murad, M. H. (2017). Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and metaanalysis. JAMA Pediatrics, 171(11), 1049 1056. Available from https://doi.org/10.1001/ jamapediatrics.2017.3036. Whiteside, S. P. H., Ale, C. M., Vickers Douglas, K., Tiede, M. S., & Dammann, J. E. (2014). Case examples of enhancing pediatric OCD treatment with a smartphone application. Clinical Case Studies, 13(1), 80 94. Available from https://doi.org/10.1177/ 1534650113504822. Whiteside, S. P. H., Dammann, J. E., Tiede, M. S., Biggs, B. K., & Jensen, A. H. (2018). Increasing availability of exposure therapy through intensive group treatment for

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childhood anxiety and OCD. Behavior Modification, 42(5), 707 728. Available from https://doi.org/10.1177/0145445517730831. Wootton, B. M. (2016). Remote cognitive behavior therapy for obsessive compulsive symptoms: A meta-analysis. Clinical Psychology Review, 43, 103 113. Available from https://doi.org/10.1016/j.cpr.2015.10.001. Wu, M. S., Lewin, A. B., Murphy, T. K., Geffken, G. R., & Storch, E. A. (2014). Phenomenological considerations of family accommodation: Related clinical characteristics and family factors in pediatric obsessive compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 228 235. Available from https://doi. org/10.1016/j.jocrd.2014.05.003.

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C H A P T E R

3 Psychoeducation for exposure therapy Cassie Lavell, Jacinda Cadman, Allison Waters and Lara Farrell School of Applied Psychology, Griffith University, Gold Coast Campus, QLD, Australia

Psychoeducation on exposure therapy The role of psychoeducation Psychoeducation is a therapeutic intervention that aims to provide an individual and their family with information about a mental health condition and its treatment (Ba¨uml, Frobo¨se, Kraemer, Rentrop, & PitschelWalz, 2006). It is considered a core component of any therapy for children and adolescents, as it can help the young person (and their family) to understand their condition, normalize their symptoms, and enhance their motivation for treatment. Psychoeducation is individually tailored to the young person’s needs, and delivered in a didactic format by the therapist, who also facilitates involvement by the young person and their family. Psychoeducation will often involve providing the child and family information about the symptoms, causes (e.g., biological, environmental), and prognosis of the presenting concern. Therapists delivering psychoeducation from a cognitive-behavioral perspective will also discuss factors that maintain the presenting concern, such as escape/ accommodation/avoidance, safety behaviors, maladaptive thoughts and beliefs, self-fulfilling prophecies, and/or distress intolerance (Westbrook, Kennerley, & Kirk, 2011). An understanding of these maintaining factors

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helps to provide the rationale for therapy, as these factors are often the targets of therapeutic interventions. In most models of therapy, psychoeducation commonly occurs following an evidence-based assessment, and prior to the commencement of other therapeutic techniques. Throughout psychoeducation, the therapist has the opportunity to build on the rapport that was established with the family during the initial assessment. This is achieved as the therapist demonstrates they understand the child’s problem, gives the child and family the chance to contribute to the formulation, and uses warmth, humor, and empathy throughout psychoeducation. Goals for therapy are commonly established during psychoeducation, as the child (and caregiver) develop more insight into anxiety symptoms at this point in treatment. Psychoeducation about treatment is also designed to instill hope for the family that achievement of these goals is possible. This is conveyed throughout the session, as the therapist shows they have the confidence and expertise to treat the problem. Empirically supported cognitive-behavioral treatments (CBT) incorporate psychoeducation for the treatment of a number of mental health disorders in children and youth, including depression (TADS Team, 2003), externalizing disorders (Barkley, 2013, 2014), anxiety disorders (Kendall & Hedtke, 2006; Walkup et al., 2008) and obsessive compulsive disorder (OCD; March & Mulle, 1998; The Pediatric OCD Treatment Study, 2004). In this chapter, we describe how to effectively deliver psychoeducation for exposure therapy in youth with anxiety disorders and their families.

Overview of psychoeducation for exposure therapy with anxious youth Psychoeducation for anxious youth and their families is an integral component of CBT, particularly those incorporating exposure therapy (Albano & Kendall, 2002; Barrett, Dadds, & Rapee, 1996; Kendall, 1994). In this context, the primary goals of psychoeducation are to: (1) provide a rationale for exposure therapy including why and how it works, (2) build rapport with the child and their family, (3) enhance the child’s motivation for and adherence to exposure therapy, (4) facilitate a family “teamwork” approach to treatment, and (5) describe how to do exposure within the session and at home. Initially (and understandably so), children and youth with anxiety disorders are likely to be frightened by the concept of facing their fears. They may also be reluctant, or even refuse, to engage with the process if they are improperly informed about what is involved. Therefore one of the first roles of psychoeducation is to enhance the child’s and

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caregiver’s understanding of the rationale for exposure therapy, and dispel any myths or unhelpful expectancies they may have about the nature of the therapy. This is designed to enhance the child’s motivation to participate in exposure, as they will be more likely to believe the treatment will be effective and lead to long-term benefits. Psychoeducation is not only for the benefit of anxious children but also their families. Research has demonstrated that CBT with family involvement is an effective treatment for youth with anxiety disorders (Ginsburg & Schlossberg, 2002; Kendall, Hudson, Gosch, FlannerySchroeder, & Suveg, 2008), as well as youth with OCD (Storch et al., 2007). In psychoeducation on exposure therapy, the therapist therefore adopts a “teamwork” approach by having the child and family attend the session together. Family involvement in psychoeducation can help to maximize the effectiveness of exposure interventions, as it is the family who will help the child follow-through with their exposure practice between the treatment sessions, and following the completion of therapy. Thus having a family support network that is well trained in the rationale and delivery of exposure will also assist with the maintenance of therapy goals, as well as relapse prevention. Therapists should carefully consider which family members might benefit from attending the psychoeducation session. Usually, this will include both or all of the child’s primary caregivers. For example, even if the child’s mother is the parent who most frequently cares for them when they are anxious, their father should also be invited to attend psychoeducation to facilitate the “teamwork” approach in therapy. Psychoeducation can also be important for other members of the child’s household, such as siblings, grandparents, or stepparents. This is because the child’s anxiety is likely to be affecting a range of family members, and moreover, those family members reactions to the child’s anxiety symptoms and avoidance may be maladaptive and misaligned with the core goals of CBT. For example, the therapist may consider who in the family is in a position to help the child with their anxiety (e.g., a grandparent who cares for the child after school), and invite them to attend psychoeducation. Alternatively, there may be family members who do not understand the child’s condition, who become frustrated or irritable with the child when they are anxious, or blame the child for their difficulties. For example, a child’s sibling who frequently teases them for their fear of the dark can be invited to psychoeducation with the goal of enhancing their empathy and support for their anxious sibling. It is sometimes the case that having certain family members present at psychoeducation may make the child uncomfortable or reluctant to attend the session (e.g., a sibling or stepparent with whom the child is in frequent conflict). In this case, if the therapist deems it to be a treatment disadvantage for that family

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member to miss out on psychoeducation, a separate session can be conducted without the child present. This will ensure the therapeutic relationship with the child is maintained, while also achieving the important goal of educating family members about treatment. Rapport building is essential during psychoeducation. Throughout exposure therapy, the therapist guides their client through a number of uncomfortable situations that they would otherwise avoid; therefore, the child needs to feel safe and supported in the therapeutic relationship in order for optimize the effectiveness of this treatment. The therapist builds on the therapeutic relationship during psychoeducation by demonstrating empathy for the child’s struggles with anxiety (e.g., “It sounds like it has been really tough for you, having to avoid all these places you used to enjoy”), showing they understand that exposure therapy will be uncomfortable, but that they will be there to guide and support them with their anxiety (“Some of the things we will be doing will no doubt make you uncomfortable, but I will never make you do something you are not ready for. Your family and I are your teammates, helping you fight against anxiety, but you are in charge of how treatment goes”). The child will be better able to develop trust in a therapist who displays warmth, empathy, and confidence when conducting psychoeducation on exposure therapy. It is important to the success of psychoeducation, that the therapist has expert knowledge of the CBT model for managing child and youth anxiety and/or OCD, specifically, how exposure therapy will assist the child in conquering his/her fears. Expert-level knowledge will help the child and parents to develop trust in their therapist and the process of exposure therapy, and likely fosters positive expectancies for therapeutic change. Therapist should take care to provide psychoeducation on exposure therapy in a developmentally appropriate way, tailoring delivery to the child’s (and caregiver’s) age and developmental level. For example, using play, stories, pictures, and metaphors can aide in interpretation for younger children; whereas, education through discussion (and reflective writing in some cases) is typically more meaningful and appropriate for adolescents. In the sections mentioned subsequently, we describe how to effectively deliver psychoeducation on exposure therapy, including: (1) introducing exposure therapy, (2) providing a treatment rationale, (3) implementing exposure therapy, (4) maximizing exposure therapy outcomes, and (5) overcoming common challenges in psychoeducation.

Introducing exposure therapy For the child and family to develop a good understanding of why exposure therapy is the treatment of choice for anxiety disorders,

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providing them basic anxiety psychoeducation is useful. To achieve this, the therapist provides information about anxiety, including that it is a normal human response sometimes referred to as the fight-or-flight response (“Anxiety is an uncomfortable feeling in our body that we get when we think we might be in danger. Anxiety and fear are your bodies alarm system that helps you to know to run away from what could hurt us”). It is important to differentiate normal anxiety/fear from an anxiety disorder, for example, “Anxiety becomes a problem when we start to have it too often, even when there is nothing dangerous around. We call these times false alarms, because anxiety is tricking us into thinking we are in danger when we are actually safe.” Together, the child, family, and therapist identify common situations that trigger “false alarms” for the child, and the physiological symptoms, or “anxious body clues,” they experience during these situations. Together, the therapist and family discuss how these body clues can be helpful and adaptive when needed, but also unhelpful when they are too strong, or not needed. The therapist also makes reference to the cognitive-behavioral model, by explaining the three components of anxiety, including anxious thoughts and appraisals (e.g., “The dog will bite me”), affect and arousal (e.g., scared, worried/ rapid heartbeat, shaking, sweating, nausea), and behavior (e.g., avoidance, reassurance-seeking, and/or compulsive behaviors). Enhancing the child’s knowledge of the cognitive-behavioral model of anxiety leads into explaining that sometimes our behavior can inadvertently maintain or exacerbate anxiety. It is important the therapist brings across to the family that in order to treat their anxiety they need to (1) face their fears, (2) reduce maladaptive behavior such as avoidance, and (3) learn through experiences that they can indeed cope with anxiety/discomfort and uncertainty. A key component of psychoeducation on exposure therapy is explaining that this process of facing fears and learning new ways of coping is done in a controlled and graded way, with therapist and family support, at the child’s pace. An example is provided below for a child with a specific phobia of dogs. Therapist

Now that we know how your phobia of dogs developed and what keeps you feeling afraid, we can start to learn about how to overcome this fear. Just as avoiding dogs or places where dogs might be keeping your fear strong, the best way to overcome your fear is to face the things that you are afraid of, and learn some new things about dogs, your feelings and how you can cope. This is what we call exposure therapy.

Child

That sounds scary. I don’t think I can do that! Maybe when I am a teenager.

Therapist

I notice you immediately looked afraid when I mentioned facing your fears. A lot of people think exposure therapy is being forced into facing their biggest fear, is that what you are expecting?

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Child

Yeah, I don’t want to have to see a big dog. Dogs can bite and jump and make a mess. I don’t really think I need to do this.

Therapist

I imagine that would be really difficult for you if you were to try and pat a big dog right now. Fortunately, that isn’t how it works. Facing your fears (or Exposure Therapy) is done at a very gradual and slow pace, with you completely in control. Your phobia has become very good at controlling your life and bossing you around, but in exposure therapy you are in charge, and are the “boss” of overcoming your fears. I will help you, but in the end, you are the one who gets to decide the steps we take when facing your fears. We start with very small and easy steps first, and only once you are ready, we move on to the next step. For example, you first step toward overcoming your fear, might be looking for a small dog, who is on a lead with its owner, through a window. How does that sound?

Child

That seems OK. I could do that.

In the case of OCD and its related disorders, there is an additional component to exposure therapy named response prevention (ERP), whereby the young person not only faces their fears (e.g., touches something they perceive to be contaminated) but also actively resists the urge to perform a compulsion (e.g., handwashing). It is important to explain to the child and family that although compulsions appear to provide some relief from distress, this relief is only temporary. In psychoeducation, the child and family learn that through performing compulsions/ engaging in avoidance behaviors, fear reduction reinforces the occurrence of obsessions and the need to ritualize, thus the child becomes trapped in an escalating cycle of OCD and fear. The child never has the opportunity to learn that distress is only temporary, and that the feared outcome (e.g., the house burning down) does not occur when they do not perform a compulsion (e.g., checking the stove three times). This is explained using a visual illustration of the “cycle of OCD” (see Fig. 3.1). Therapist

You told me you don’t want to keep doing your habits. Why do you think you keep doing them when you don’t like them?

Adolescent

I try to stop the habits all the time, but I get so stressed that I just have to give in.

Therapist (referring to Fig. 3.1)

It sounds like you are getting stuck in the cycle of OCD. It starts with an obsession. An obsession is a scary thought like “What if the house burns down?” How do you usually feel when you have a thought like this pop into your head?

Adolescent

Really uncomfortable, like something bad is definitely going to happen. So I go back and make sure the stove is off.

Therapist

Exactly. The obsession makes you feel afraid, and then to feel better you go to do a compulsion—such as going back and checking the stove. How do you feel once you have checked the stove?

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Obsession "The house could burn down"

Temporary relief from anxiety

Anxiety

Compulsion, for example, check the stove is off four times

FIGURE 3.1

Illustration of the “cycle of OCD” in psychoeducation on ERP.

Adolescent

I feel better—but the thought often comes back and I have to go and check again.

Therapist

That’s the cycle of OCD. OCD has tricked you into thinking the only way to feel better and stop bad things from happening is to do a compulsion. This is a trap. If you go back and check, you never learn that the house doesn’t burn down, that you can cope with having a feeling of doubt or a silly thought, and that your fear does go away on its own. So, to overcome OCD we have to start to break the cycle, which means starting to fight the habits. When people start to resist them, they learn that their anxiety is actually not so bad, and that it does pass, and nothing bad happens. This is called exposure with response prevention, or facing and fighting OCD. To overcome OCD, we need to face the fear and fight the urge to do a habit. For example, leave the house after someone has used to the stove, and resist the urge to go back and check they turned the stove off.

Adolescent

I see what you mean, but I have tried resisting them before and I just can’t.

Therapist

I’m going to teach how to face and fight OCD in a way that will set you up for success. This means facing small fears first, and building up doing harder steps. And since you know your OCD much better than I do, you are going to be the boss of facing and fighting OCD. I will be here as your teammate, but you get to be in charge of how treatment goes.

During psychoeducation, the therapist can also enhance the child’s motivation for exposure therapy (or ERP), by starting to externalize the

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problem. This involves using a narrative approach to language that highlights how anxiety or OCD are the cause of the child’s symptoms, as opposed to the child being to blame for not controlling his/her fear (e.g., “It seems anxiety/OCD have become very strong and bossy, making you avoid all these things when you just want to enjoy your life”). Externalizing anxiety or OCD can also be achieved by having the child create a nickname, and draw what anxiety/OCD looks like to them during psychoeducation. The child’s anxiety disorder is referred to by its nickname for the rest of psychoeducation and treatment. This serves to cultivate detachment from the symptoms, helping the child to ally with the therapist and family, in order to fight against their anxiety and/or OCD symptoms. It is also encouraged that the family externalize the problem also, which serves to reduce frustration towards the child, and redirect any such anger toward the symptoms, while fostering support and empathy with their child. For example, parents are encouraged to verbalize when they notice their child struggling with symptoms, in a way that externalizes the problem and empowers the child. For example, “I can see that OCD Loser is bossing you around—what can we do to boss back together?” The therapist also uses phrases like “fighting anxiety” and “bossing back” in psychoeducation, to give the child hope, foster empowerment, and encourage control of their symptoms.

Providing a treatment rationale Once the young person and their family understand what exposure therapy involves, it is important to explain how the treatment is effective. When describing how exposure therapy works, the therapist draws from theories of extinction learning (Foa & Kozak, 1986) and inhibitory learning models (see McGuire et al., 2016). During psychoeducation, the family learn about these underlying process, whereby with continued exposure to feared stimuli, the fear response (1) reduces over time as the child gets used to the stimuli (i.e., through habituation), (2) the child learns to tolerate anxiety and discomfort, and (3) learns new information about the feared stimuli, outcomes of facing the stimuli, and their ability to cope, which violate the child’s previous fear expectancies regarding threat and coping (i.e., through inhibitory learning). This explanation can also be aided by visual illustrations. Firstly, the therapist shows that avoidance leads to a sudden drop in anxiety in the short term, but ultimately this leads to maintained or even worsened anxiety over time. The therapist can then demonstrate that during exposure, anxiety may increase in the short term, but over time (approximately 10 15 minutes), this anxiety often reduces, and with repeated exposure, the task becomes

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Anxiety rating

Providing a treatment rationale

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9 8 7 6 5 4 3 2 1 0 Time Anxiety with avoidance First time remaining in the situation without avoidance Second time in the situation without avoidance Third time in situation without avoidance

FIGURE 3.2 Illustration of habituation for use in psychoeducation on exposure therapy.

easier. See Fig. 3.2 for an illustration that can be used in psychoeducation to explain the process of habituation in exposure therapy. Therapist (referring Fig. 3.2)

When we get close to something we are afraid of, our anxiety usually goes up. This starts to feel really uncomfortable and often we will avoid it or escape. Once we escape, our anxiety goes away and we feel better. This feels good in the short term, but the next time we face what we are afraid of, we go through the same cycle again. But if we were to decide to stay in the situation without running away, we would start to see that we are safe and nothing bad happens, and our anxiety would start to come down. And then the next time we had to face that fear, we would be a little bit stronger—because we know nothing bad happens, and that we can deal with anxiety. And each time, we face the fear, it gets easier and easier, and takes less time for anxiety to come down.

During psychoeducation, the child and family also learn about the inhibitory learning that takes place during exposure; that is, the process through which the fear association is inhibited by the new non-fear association. To achieve this, the family are taught that, during exposure, new learning will take place including challenging expectations about feared outcomes, and challenging beliefs about anxiety and discomfort. The therapist explains to the family that during exposure therapy, the child will learn that they can tolerate and cope with anxiety, and that anxiety is not harmful and will pass.

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Therapist

The Worry Monster has been telling you that you can’t cope with being anxious, and that anxiety is bad and won’t go away. But we know that anxiety is just tricking you! I am going to show you in treatment that you are strong and brave and can deal with anxiety. We are also going to learn that some anxiety is indeed manageable, and that you are perfectly safe. This means that the next time you have to face your fear in everyday life, you will remember what you have learned in exposure practice, and believe that you can be brave, face your fears, and know that you will cope with whatever happens!

The therapist also describes how anxious beliefs and expectancies for threat and danger will be violated during exposure. It is important for the child to learn that in exposure therapy their worst fears are actually very unlikely to occur, and that while some negative outcomes may occur (e.g., while giving a speech in class someone laughs or snickers), these are not usually as bad as their worst fear (e.g., the whole class laughs at you). For example, a child with OCD may fear that if they resist their compulsions, they will get sick or injured. The therapist therefore explains that exposure therapy is designed to test these expectations so that they no longer need to avoid certain things or do compulsions to prevent bad things from happening. Therapist

Another way that OCD tricks you, is by telling you that something bad will happen if you don’t do your habits, for example that you could get hurt. Through exposures, we are going to learn that your avoidance (or habits) do not stop anything bad from happening, and the chances of something bad happening are actually very low. Therefore, you will learn a lot of new things through facing your fears. For example, most often NOTHING bad happens when we face our fears. Sometimes, even GREAT things happen, like you rise to the challenge and cope like a superhero. And sometimes bad things do happen (that’s life right!)—BUT, these things are never as bad as we think, and YOU will COPE even when it’s tough. You are going to learn ALL of these new things through exposure therapy.

After explaining the rationale for treatment, including the processes of habituation and inhibitory learning, it is important to check-in with the child and family as to how they are now feeling about engaging in exposure therapy (e.g., “What are your thoughts on exposure therapy, now that we’ve spoken about how it works?”), ask the child to explain back the information in their own words to check their understanding, and answer any further questions they may have about the treatment rationale.

Implementing exposure therapy (and response prevention) The text below provides a guide for clinicians on educating children and their families about how to complete exposure therapy. At this

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point in the psychoeducation phase, families understand that exposure therapy is the main focus of future treatment sessions, and will likely be excited (or anxious) to learn more about how this “looks” in session and at home. After providing families with information surrounding the rationale for exposure therapy, the next step is to illustrate to the client (and family) exactly how theory is put into practice, specifically through the development of exposure hierarchies. Concrete examples are used to detail how this therapy approach is executed, and in doing so, provides support for children and their families about both the structure and pace of subsequent exposure-based therapy sessions. As is the case throughout the psychoeducation phase, a collaborative “teamwork” approach is encouraged in order to develop a shared understanding of the child’s anxiety, and to increase adherence to treatment. Providing examples of how to complete exposure therapy should, therefore, maintain involvement of both the child and appropriate family members. The therapist should also frequently check on the client’s (and caregiver’s) understanding throughout this part of psychoeducation, to confirm their understanding of how to complete exposure therapy and address any confusion, concerns, and/or anxiety promptly. Engaging families can be further increased during this phase of treatment by involving them directly in developing example exposure hierarchies, sometimes by having them draw on their own experiences of anxiety. Establishing a clear way of communicating about the intensity of anxiety using a rating scale (see Fig. 3.3) is essential to be able to complete effective exposure therapy with children and adolescents, and should be introduced during the early stages of treatment. It empowers the child throughout exposure therapy to be able to express when exposure-based tasks feel too difficult, and helps the therapist to illustrate the process of habituation that occurs during an exposure task. The rating scale is initially used during psychoeducation, however, to identify which exposure tasks the child finds more or less anxiety provoking—a necessity when developing an exposure hierarchy with the child. Explaining to the child and their family that exposure therapy is graded, whereby initial exposure steps are designed to elicit minimal anxiety (i.e., a 2 3 on the rating scale), before the difficulty is gradually increased, is helpful to strengthen “buy-in” and to maintain a good therapeutic relationship. By introducing a symptom monitoring table, the therapist can also further “map” the child’s worries and identify which situations cause them more or less anxiety. This is a helpful tool for all anxiety presentations, including, for example, phobias (see Fig. 3.4) and OCD (see Fig. 3.5), and provides the child with an opportunity to put their rating scale into action. The child will notice that various symptoms will cause

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FIGURE 3.3 Example rating scale for anxiety.

MAPPING MY FEARS Situation that makes me feel scared Walking the dog Friend speaking about spiders Watching the National Geographic channel Having BBQ outside Going to bed

Behavior

Thermometer Rating (0–10)

Avoid walking the dog at parks, stick to pathways only

5

“Yuck, they’re disgusting”

Tried to block out my friend, look around me for spiders

3

“Oh no, what if a spider appears onscreen! I won’t be able to cope”

Avoid watching National Geographic channel (family to avoid also)

6

“A spider will get into my dinner and I’ll eat it”

Refusal to eat outside with my family

7

“A spider will be in my bed sheets and will bite me”

Make mum check my bed and then remake it before I hop in

9

Worry

“What if I see a spider?”

FIGURE 3.4 Monitoring table for specific phobia of spiders.

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Implementing exposure therapy (and response prevention) MAPPING OCD SYMPTOMS Situation that makes me feel uncomfortable

Sitting in the car

Obsessions (thoughts)

“The car seat has been contaminated by my brother”

Compulsions (habits or avoidance)

Place a clean towel on the car seat

“What if someone else has touched my toothbrush and it’s not clean?”

Keep toothbrush in my bedroom

“If I don’t have a good thought when putting my clothes on then my day will be ruined”

Repeating dressing until I have a good thought

Eating breakfast

“What if mum poisoned me?”

Refuse to eat. Make mum remake my breakfast.

Going to sleep

“I might wake up a different person”

Brushing my teeth

Getting dressed

Thermometer Rating (0–10)a

Say a prayer 10 times without a bad thought and place all my toys in an exact place

6

4

5

9

10

a

For your thermometer rating – remember to ask yourself, how distressed would you feel if you couldn’t do your compulsion?

FIGURE 3.5 Monitoring table for OCD.

different levels of anxiety on their rating scale, thus confirming that it is possible to break down their worry into more manageable steps. At this point, it is recommended to reiterate to the child again that the symptoms endorsed that cause them the least anxiety will be the initial focus for exposure therapy, for example, “Even though the thought of touching a spider feels impossible to you right now, there may be smaller, more manageable steps that we can work on first.” It is also recommended that the child, with the help of their family, continues to map their anxiety for homework during the psychoeducation phase and early treatment phase, so that all symptoms are identified and can be appropriately targeted in exposure therapy (either in clinic or at home). Following this, exposure hierarchies, or stepladders, can be introduced by generating example stepladders with the client’s assistance (see Appendix 1 for a template). First, the therapist should assist the child to identify a treatment goal to be inserted at the top of their hierarchy. This goal should include a clear and specific behavior to achieve, for example, a child fearful of staying away from home may identify a stepladder goal “To attend a friend’s sleepover.” Once a specific hierarchy goal has been established, individual steps can be defined, starting at step 1. The child’s first step on the hierarchy should be achievable and minimally anxiety-provoking to ensure that the child is set up for success from the start. With the child’s help, the therapist can then I. Basics of exposure therapy for children and adolescents

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My facing fear step plan for: STEP 6 – GOAL To attend a sleepover at my best friend’s house.

STEP 5 To stay overnight at a close/less close friends house with a visit from mum to tuck me into bed.

STEP 4 Have a sleep over with my friend, in a tent in my backyard.

STEP 3 Have a sleep over in my brother’s bedroom without him there.

STEP 2 To stay at a close/less close friends house until dinner.

STEP 1 To go to a close (then less close) friend’s house during the day, then pick-up at dusk.

FIGURE 3.6 Example stepladder for staying away from home.

continue to work up the stepladder, increasing the difficulty of each step gradually (see Fig. 3.6). Incremental steps should be guided by the child and can be as small or slight as is required. Asking the child to contribute to the development of each step emphasizes the control assigned to them in therapy, while reinforcing their understanding of exposure therapy. Given the role of family accommodation in maintaining fear and anxiety, the therapist can also create stepladders with the child and their parents that aim to gradually reduce behaviors such as family avoidance of anxiety triggers, providing reassurance, and other safety behaviors. If the child is having difficulty completing a stepladder for an area of their own concern, then it may be useful to talk them through an example for a friend, family member, or stranger. For example, asking the child: Therapist

If I was scared of dogs, how might you help me to overcome my fear? Would you tell me, “Never go near them again, they might bite you!” or would you instead encourage me to start off small, like looking at pictures of puppies,

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then watching dogs in the park, and gradually build up to patting a dog, so that I can learn that dogs won’t hurt me after all?”

Creating a stepladder in this way is helpful for the child to see the utility of the therapy approach, and to provide them with an opportunity to be the expert. Subsequently, generalizing to an area of their own concern appears more manageable. Exposure hierarchies can be introduced similarly for young people presenting with OCD. The main difference for these children is the role of response prevention. Exposure and response prevention (E/RP) tasks will therefore involve the child facing their OCD fear (e.g., that something bad will happen to a loved one), and resisting completing their usual OCD compulsion (e.g., completing a bedtime ritual; see Fig. 3.7). The therapist should explain that while complete response prevention is the goal, when this presents as too challenging, the E/RP task may include delaying, changing, or reducing the compulsion. Compared to a specific fear or phobia that may require only one stepladder, children presenting with OCD may require several stepladders, depending on the number of OCD symptom domains experienced. For example, if a child presented with contamination obsessions, as well as evening up, and checking rituals, then they would develop three stepladders for each of these three symptom domains (or faces of OCD). Additionally, it is also common for young people presenting with OCD to be required to develop stepladders for family members who are engaging in significant accommodation of OCD obsessions and rituals (e.g., buying cleaning My facing and fighting back step plan

STEP 6 – GOAL To be able to go to bed without ritualizing.

STEP 5 Saying “good night” only at bedtime.

STEP 4 Mum to face back to child during bedtime ritual and nod rather than respond “I love you back.” STEP 3 Replace speaking “I love you” with “I love you” hand gestures. STEP 2 Shorten bedtime ritual by reducing number of “I love you” repetitions. STEP 1 Delay bedtime “I love you” ritual by 5 minutes.

FIGURE 3.7 Example stepladder for harm-based OCD.

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products, avoiding saying certain words, or providing reassurances). Emphasizing to family members that their accommodation of OCD will be addressed in the same way as the child’s other compulsions (i.e., gradually and with the child in control), is important at this stage of treatment. Through this discussion, families feel reassured that they have a clear plan for managing their child’s OCD symptoms, and the child is also reassured that treatment will always move at their pace. In order to achieve consistent gains in exposure therapy, both insession and between-session practice is critical. Explaining to the child and their family during the psychoeducation phase, the importance of regular practice in achieving change ensures appropriate expectations about treatment. In addition to in-session exposure, which will be the focus of future treatment sessions with the child, exposure tasks will also be set for home-based practice. Exposure tasks should be practiced often, daily where appropriate, and in some cases up to several times each day, for example, a child presenting with OCD checking rituals may practice exposure to not checking that the doors are locked whenever they leave the house throughout the day, such as when going to school, walking the dog, and attending sports training. Although exposure therapy will be most effective when practice is generalized to a variety of situations, if some situations are deemed more difficult than others (e.g., not checking the door before school is harder than not checking before walking the dog) then this should be addressed in the development of the child’s exposure hierarchy. Although the reduction in anxiety that is achieved through the practice of exposure-based tasks for some may be reward enough, for most children additional reward-based incentives can significantly increase compliance and motivation in treatment, particularly for betweensession exposure practice. It is recommended that the therapist supports the family to develop a rewards menu during psychoeducation (see Fig. 3.8). Depending on the age of the child, immediate or daily rewards should also be considered. Rewards may also be useful to increase motivation for in-session exposure practice, and should be agreed upon with the family beforehand.

Maximizing exposure therapy outcomes Although exposure therapy is an effective approach for treating anxiety disorders in approximately 60% of anxious children (see Dowell, Donovan, Farrell, & Waters, 2018), a substantial number fail to benefit or experience a return of fear and anxiety after treatment (Ginsburg et al., 2014). Experimental psychopathology research has advanced

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Weekly rewards for facing my fears • • • • • • • • • • • •

Trip to the local park/beach after school ½ hour TV time ½ hour Ipad or Computer game time Download an Ipod/Iphone App Stickers Small stationary item—Rubber, pencil or post it notes Staying up ½ hour past usual bedtime Choosing the evening meal that mum or dad cooks Playing a board/card game with mum or dad Piece toward a lego set (or other toy set) Collector card or item Arts or craft items

5 points 5 points 5 points 5 points 5 points 5 points 5 points 5 points 5 points 10 points 10 points 10 points

Long-term rewards for facing my fears • • • • • • • • • •

Buying a new book Going to the movies Going to a football game Going on a family picnic Eating out at a favorite restaurant Itunes gift card Arts and craft kit Having a friend sleep over Going to a theme park Going camping for a weekend

15 points 20 points 20 points 10 points 20 points 10 points 20 points 20 points 40 points 50 points

FIGURE 3.8 Example rewards menu.

knowledge about underlying mechanisms and translational augmentation strategies that may enhance outcomes from exposure therapy (Waters, LeBeau, & Craske, 2017). In contrast to habituation models of exposure therapy which posit that fear reduction during an exposure trial is a necessary precursor to enduring cognitive changes in the perceived risk and danger associated with the feared stimulus (Foa & Kozak, 1986), a major cross-cutting theme of novel approaches derived from experimental psychopathology research is the enhancement of engagement and arousal during exposure therapy in order to enhance corrective learning and thus, fear reduction (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Examples of how to apply this to exposure therapy are outlined subsequently.

Avoid distraction from/interference with processing the new conditioned stimulus—no unconditioned stimulus association Minimizing therapy and client variables that might prevent children from fully processing the new stimulus contingencies during exposure trials is crucial for effectively challenging clients’ expectancies and

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evaluations. In terms of child variables, recent experimental psychopathology studies have demonstrated that visual attention avoidance of the conditioned stimulus (CS) during extinction trials/exposure therapy trials is associated with impaired extinction of fear responses, more generalization of fear responses to neutral stimuli, greater retention of fear responses at retest, and poorer treatment outcomes following exposurebased CBT (Niles, Mesri, Burklund, Lieberman, & Craske, 2013; O’Malley & Waters, 2018; Price, Tone, & Anderson, 2011; Waters & Kershaw, 2015; Waters, Mogg, & Bradley, 2012; Waters, Potter, Jamesion, Bradley, & Mogg, 2015). Thus it is important that therapists monitor children’s visual attention to ensure they are attending to the CS and processing the nonoccurrence of the unconditioned stimulus (US) in order to maximally violate discrete CS US expectancies and prevent fear responses generalizing to other stimuli to which attention may be transferred in order to downregulate distress (Waters & Craske, 2016). In terms of therapy variables, it may also be instructive to reduce the presence of other stimuli to which children might transfer visual attention by removing other salient or distracting stimuli from the exposure trial environment (Waters & Craske, 2016). Relatedly, the removal of safety signals may be important to prevent interference with the development of new learning (e.g., cuddly toy, a special water bottle, lucky charm, and even parents) on the basis that safety signals in the experimental literature have been shown to alleviate distress in the short term, but are linked to return of fear in the long term (e.g., Lovibond, Davis, & O’Flaherty, 2000; Sloan & Telch, 2002; see Sy, Dixon, Lickel, Nelson, & Deacon, 2011 for differing findings). Although their removal all together is optimal, gradual fading out of safety signals may be required to prevent attrition (Hermans, Craske, Mineka, & Lovibond, 2006), especially with children. Finally, therapists often encourage active cognitive processing of changing stimulus events and fear responses during exposure trials. However, this too may interfere with engagement in the exposure trial itself. For example, shifting attention inwardly to emotional responses and engaging in elaborative stimulus reevaluation is likely to increase cognitive load and draw attention away from changing stimulus contingencies (Waters & Craske, 2016). Indeed, experimental and treatment research suggests that extinction learning/exposure therapy may be strengthened and outcomes improved when changes in US expectancies and evaluations of the CS and one’s coping are assessed after rather than during extinction/exposure trials (Waters, Farrell, et al., 2014; Waters & Pine, 2016). Taken together, therapists can maximize exposure therapy by ensuring client and therapy variables do not inadvertently encourage avoidance of attending to, and processing, changing CS US associations that take place during extinction/exposure trials.

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Therapist

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Sometimes it can be harder to learn that vomit will not harm you and that you can cope with it when you have other things around that grab your attention and make you feel safe. They can stop you from looking at the vomit and make you think you coped because you had Joey here (favorite toy). So today, we are going to start with just the bowl of vomit on the table and Joey here too, and after a while, we will put Joey one the couch outside for a rest.

Strategies to enhance arousal and engagement during exposure therapy A further way in which exposure therapy may be optimized is by targeting therapy and client variables that are likely to increase engagement, arousal, and unpredictability. To some extent, these strategies are designed to enable children to learn through exposure trials that stimulus events can change and that they can cope with them. In doing so, these more “arousing” forms of exposure trials may assist with the realignment of underestimation biases in children’s evaluations of their coping efficacy (Waters & Craske, 2016). Enhancing variability during exposure trials may enhance engagement in several ways, including making the learning task more salient and memorable (Bjork & Bjork, 2006), linking the new learning with more retrieval cues (Estes, 1955), and drawing attention to nonemotional stimuli in the learning task (Magill & Hall, 1990). A number of strategies have been examined in the experimental and treatment literature that serve to enhance variability during extinction/ exposure trials. For example, the use of multiple stimuli representative of the feared stimulus during extinction (e.g., exposure to dogs of varying size and color) has been found to increase arousal during extinction yet increase generalization of extinction learning to novel stimuli and prevent return of fear compared to the conditioned stimuli alone (Hermans et al., 2005; Rowe & Craske, 1998; Waters, Kershaw, & Lipp, 2018). Conducting exposure trials in multiple different contexts (e.g., therapist office; car park; local park) also enhances extinction learning and prevents relapse (Balooch, Neumann, & Boschen, 2012; Vansteenwegen et al., 2007). Furthermore, increasing the duration of time between exposure sessions may increase treatment outcomes compared to massed exposure with constant intervals between sessions (Lang & Craske, 2000). Therapist

What makes us learn really well that dogs are okay and that we can cope with them is to practice with lots of different dogs in different situations. This helps our brains learn that not just one but lots of dogs are okay, even when you come across them in different places, like at a friend’s house, playing in the

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park, and going to Grandma’s house. The more we practice looking at and learning about different dogs in different places, the more memories our brain has of us coping and keeping calm.

Arousal and engagement may also be increased by exposure hierarchies that are conducted in a variable order rather than in a graduated format from the lowest to highest fear rating. Such variability typically elicits higher levels of physiological arousal and subjective anxiety during exposure that fail to habituate (e.g., Kircanski et al., 2012; Lang & Craske, 2000), and yet produce beneficial effects in the long term. For children, this could be adapted to avoid attrition by varying the order of the lowest three exposure steps, then the middle three exposure steps and finally the highest three exposure steps. To some extent, components of “overlearning” apply to the principal of enhancing variability, whereby children complete exposure tasks with stimuli that exceed what they would encounter in daily life (e.g., for a child with OCD, eating food off a toilet seat), and furthermore, they continue to practice and rehearse coping responses well beyond when their fear levels have declined. Therapist

Not only does it help learning about different dogs in different places, it helps even more to mix up the order of the dogs and the places we learn about them in. That’s why one of the steps you came up with is walking the dog in the shopping center. You wouldn’t usually do that, but it makes your brain have a really strong memory of you coping with the dog, especially when you do it lots and lots of times rather than just once. So let’s put these three dog pictures in the cup and pull out one at a time to make the lower steps in the Step Ladder and then the other three dogs to make the top three steps.

Variability may also be achieved by the occasional exposure trial in which the CS is reinforced with the US, either intentionally or accidentally (e.g., a child afraid of water falls from the boat with the force of a passing wave). Occasional reinforced exposure trials increase arousal during extinction/exposure trials but attenuate return of fear (Culver, Vervliet, & Craske, 2015). Occasional experiences of the US during extinction may increase the salience of the CS and thus active processing of stimulus contingencies as well as enhance opportunities for the reevaluation of coping self-efficacy (e.g., “I fell in, but I was okay”; Culver et al., 2015; Waters & Craske, 2016). Taken together, all strategies aimed at enhancing variability during exposure serve to elevate arousal and engagement. Greater arousal and engagement may in turn enhance the salience of extinction learning taking place during exposure trials and thus serve as a retrieval cue of extinction when subsequently reexposed to the CS.

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Therapist

Oh look at that. The dog actually jumped up on you and what did you notice?

Child

I got a fright. I wasn’t expecting that. He was heavy and nearly pushed me over.

Therapist

What do you notice about his tail?

Child

It is wagging?

Therapist

What do you think that tells you about the dog?

Child

He was excited and wanted to play?

Therapist

What do you notice about yourself now?

Child

I am alright. It didn’t hurt. I just got a fright.

Therapist

Sometimes the best thing that can happen is what you’re most afraid of. It helps your brain learn that even when unexpected things happen, you can cope with it and actually it might not be as bad as you thought.

Strategies to enhance the consolidation of corrective learning In the context of exposure trials that minimize avoidance of and interference with processing the CS and the nonoccurrence of the US and elevate arousal and engagement by enhancing variability and unpredictability, exposure therapy outcomes may be improved by additional strategies that explicitly aim to enhance learning. For example, increasing positive affect via positive imagery training prior to extinction/exposure trials improved negative CS evaluations after extinction and reduced a return of fear compared to positive verbal training (Zbozinek, Holmes, & Craske, 2015). Furthermore, attention training to positive stimuli prior to intensive exposure therapy for youth with specific phobias significantly reduced children’s danger expectancies about their feared situations/object during exposure therapy and at threemonth follow-up, and significantly improved attention bias toward positive stimuli at posttreatment, which in turn, predicted a lower level of clinician-rated phobia diagnostic severity three months after treatment (Waters, Farrell, et al., 2014). In addition, drawing from the memory reconsolidation literature, reactivation of fear memories by brief exposure to the feared stimulus within 1 hour prior to extinction/exposure trials may prevent relapse (Agren et al., 2012; Monfils, Cowansage, Klann, & LeDoux, 2009; Shiller et al., 2010). Several strategies utilized by clients during extinction/exposure trials have also been found to have beneficial effects on corrective learning. For example, verbalizing strategies to attend to the stimulus at hand (i.e., “look and learn”) and to retain that learning (i.e., “lock it in”) reduced generalization to neutral stimuli under conditions of

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uncertainty and enhanced extinction retention when sustained attention was required compared to extinction trials without verbalization (Howley & Waters, 2017). Similarly, labeling negative words during extinction/exposure trials whether relevant or not to the feared stimulus (e.g., gun; war) reduced arousal during extinction/exposure trials and return of fear compared to non-labeling control conditions (Kircanski et al., 2012). Of note is that these linguistic strategies enhance the salience of the stimuli to be processed rather than involving elaborative cognitive processing and explicit stimulus reevaluations, which may interfere with engagement in the learning taking place during exposure therapy. Finally, the inclusion of retrieval cues of the CS no US association during extinction/exposure trials, so that these cues can be used in other contexts to retrieve extinction learning and prevent return of fear, may be more beneficial if they focus on mental reinstatement of what was learned during exposure sessions rather than explicit cues such as a pen or clipboard (Mystkowski, Craske, Echiverri, & Labus, 2006). Moreover, it is particularly important that retrieval cues be introduced towards the end of exposure therapy as a relapse prevention strategy so that they do not become a safety signal (Dibbets, Havermans, & Arntz, 2008). Taken together, numerous strategies during exposure therapy may assist children process and consolidate new learning taking place during exposure therapy including the verbalization of therapeutic strategies, affect labeling, and mental recall of what was learned during exposure trials. Each of these strategies can be readily applied with children and may be helpful augmenting strategies to implement if routine exposure therapy practices are proving ineffective, a topic which is expanded upon in the next section. Therapist

When we look at the dog next time, it helps your brain to remember to look at the dog if we say to ourselves “look and learn.” It helps to override the urge to look away or leave, and that means we get to stay long enough to see that nothing terrible will happen. Afterward, it is helpful to say something like “lock it in” to help your brain remember what you just learned—i.e., that the dog will not harm you and you can cope.” Let’s practice it with a picture first. When you see the dog, say out loud “look and learn” and after I remove the picture, say out loud “lock it in.”

Overcoming challenges encountered in psychoeducation for exposure therapy Psychoeducation marks the beginning of formal therapy for children and their families, and provides a unique opportunity to foster hope and cultivate a readiness for change. In this way, psychoeducation may

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be viewed as process of socializing the child and their parents to the treatment process, therapy approach, and roles of all participants— including the therapist, child, and family. One of the major challenges that can be encountered in the psychoeducation session is when parents (or indeed the adolescent) are pessimistic and inflexible in their beliefs about either their child’s capacity for change, or the effectiveness of the therapy. In these instances, it is often helpful to meet the parents (or teenagers) resistance with empathy and curiosity, whilst also containing the parents’ frustrations when they become critical of the child. Through validating the parent’s perceptions, and normalizing their responses and beliefs, the therapists avoid becoming stuck in trying to persuade the parent, but rather fosters understanding and empathy, while also posing a way forward which may provide the family a different way of understanding and managing the child’s anxiety. Therapist

It sounds like it has been extremely difficult and frustrating—not only for your son/daughter, but also the entire family. I can imagine it has been distressing, annoying and even infuriating at times to watch your child become consumed with these senseless worries (and/or habits). When you love your child, as much as all parents do, there is often nothing more confronting for a parent, then being unable to help them. Your experience is indeed one that many, if not all, parents have struggled with at some stage when trying to understand and help their anxious child. The fact that you are all here today means that you are doing something different. Today marks the beginning of seeing this problem differently, indeed, of everyone in the family, working together, to see this problem differently. When we work together, and understand how anxiety (or OCD) has trapped your child, and often hijacked the entire household, we can start to tackle this problem together. When we unite and ally together, we are stronger, and more likely to succeed. So, whilst trying something new is uncomfortable and hard, doing nothing is often much more uncomfortable. My job will be to help support ALL of you— especially mum and dad, because they will be your biggest supporters for the rest of your life! How about we take it one step at a time, and we can test out together what works best for you all?

Another challenge that can surface during the early stages of psychoeducation is resistance from the child. Resistance and reluctance to engage in the session from an anxious child is often the result of fearfulness, anxious arousal, and avoidance. These feelings may present as the child being quiet and withdrawn, teary and anxious, or oppositional. It is again important to validate the child’s internal experience, normalize their reactions, and once again highlight the teamwork approach. For example, “coming along to see me can be scary and difficult to begin with. This is because your fear and anxiety have been bossing you around for a long time. You have probably tried a lot of things in the past, some things which were helpful, and other things which may not

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have worked, so you might worry this is a waste of time. My job is to help children and families just like yours. It’s not going to be easy, but it will become easier—and we might even have some fun. The good news—it’s not only you who will learn some new things. You and I are going to teach mum and dad some new things too!” Therapist can deliver the education material to the parents, asking the child to provide “expert examples” along the way, allowing the child the opportunity to warm up over the course of the session whilst not being in the spotlight. Using humor and a lighthearted approach can also assist in diffusing anxiety and resistance. For example, “you probably didn’t realize, but anxiety is normal and almost everyone I know has something they are afraid of, or were afraid of. What do you think your mum or dad were afraid of when they were little? I bet your dad was super scared of the dark, or maybe heights? Maybe your mum was scared she might wet the bed? When I was little, I used to worry that there were sharks in my backyard pool!!! I was so scared that I couldn’t jump in unless someone was in with me. I imagined the sharks flew from the beach at night while I was asleep and landed in my pool! See, we all have fears. Even the most intelligent, smart, and wise of us—like your mum, dad, and you!” Finally, a frequently encountered challenge occurs when psychoeducation has actually proceeded very well, and both the child and family are engaged and onboard. The problem however arises when parents become overly enthusiastic to kick-start exposure therapy immediately, or similarly the child’s eagerness results in the child wanting to face all of their fears at once. It is helpful to foresee this as a common experience of children and their families who are committed and eager, and discuss this within the psychoeducation session. Therapists can praise the family and the child for being excellent clients, who are well on the way to successfully overcoming anxiety and/or OCD; however, the therapist can also caution the family about taking things slowly to begin with, to ensure the child is most likely to experience success. The therapists can use the “tortoise and the hare” fable to illustrate the point, recommending the child approaches exposure therapy much like the tortoise—slow and steady. Once the initial stages of exposure are a success, children can be assured that they can fly through their treatment at record-breaking speed! For parents, it is important that they remember that exposure therapy (including the reduction of parental reassurance or accommodation) occurs at the child’s pace, and under the child’s control, whereby the child will let the parent know when they are ready for the parents to reduce behaviors.

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Concluding remarks Psychoeducation for exposure therapy sets the context for this powerful and efficacious treatment for childhood anxiety and OCD. A carefully planned, collaboratively delivered session can achieve an early positive response in therapy, and may determine the child’s engagement in, and longer term outcomes to exposure therapy. Psychoeducation should aim to engage, socialize, and motivate a child and family for what lies ahead in therapy, and above all else, foster a positive, trusting relationship between the child, family, and therapist. The CBT therapist for childhood anxiety and OCD approaches this session with expert knowledge of the cognitive-behavioral model of anxiety, and delivers this important educational material in a manner that is evidence-based, theoretically derived, and developmentally tailored. Following a successful psychoeducation session, children, adolescents, and their families should be equipped with the knowledge and skills to approach exposure therapy with confidence and readiness, and have faith in their therapists to expertly deliver this treatment.

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Appendix 1

My facing my fears step plan for __________ ____________________ STEP 6 - GOAL

STEP 5

STEP 4

STEP 3

STEP 2

STEP 1

References Agren, T., Engman, J., Frick, A., Bjorkstrand, J., Larsson, E. M., Furmark, T., & Fredrikson, M. (2012). Disruption of reconsolidation erases a fear memory trace in the human amygdala. Science, 21, 1550 1552. Albano, A. M., & Kendall, P. C. (2002). Cognitive behavioral therapy for children and adolescents with anxiety disorders: Clinical research advances. International Review of Psychiatry, 14, 129 134.

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Balooch, S. B., Neumann, D. L., & Boschen, M. J. (2012). Extinction treatment in multiple contexts attenuates ABC renewal in humans. Behaviour Research and Therapy, 50(10), 604 609. Barkley, R. A. (2013). Defiant children: A clinician’s manual for assessment and parent training. Guilford Press. Barkley, R. A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Publications. Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333. Ba¨uml, J., Frobo¨se, T., Kraemer, S., Rentrop, M., & Pitschel-Walz, G. (2006). Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin, 32, S1 S9. Bjork, R. A., & Bjork, E. L. (2006). Optimizing treatment and instruction: Implications of a new theory of disuse. In L. G. Nilsson, & N. Ohta (Eds.), Memory and society: Psychological perspectives. New York: Psychology Press. Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximising exposure therapy: An inhibitory learning approach. Behaviour, Research and Therapy, 58, 10 23. Culver, N. C., Vervliet, B., & Craske, M. G. (2015). Compound extinction: Using the Rescorla-Wagner model to maximise exposure therapy effects for anxiety disorders. Clinical Psychological Science, 3, 335 348. Dibbets, P., Havermans, R., & Arntz, A. (2008). All we need is a cue to remember: The effect of an extinction cue on renewal. Behaviour Research and Therapy, 46(9), 1070 1077. Dowell, T., Donovan, C. L., Farrell, L. J., & Waters, A. M. (2018). Treatment of anxiety in children and adolescents. Current Treatment Options in Psychiatry, 5, 98 112. Estes, W. K. (1955). Statistical theory of distributional phenomena in learning. Psychological Review, 62, 369 377. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20 35. Ginsburg, G. S., Becker, E. M., Keeton, C. P., Sakolsky, D., Piacentini, J., Albano, A. M., & Kendall, P. C. (2014). Naturalistic follow-up of youths treated for pediatric anxiety disorders. JAMA Psychiatry, 71(3), 310 318. Ginsburg, G. S., & Schlossberg, M. C. (2002). Family-based treatment of childhood anxiety disorders. International Review of Psychiatry, 14, 143 154. Hermans, D., Craske, M. G., Mineka, S., & Lovibond, P. F. (2006). Extinction in human fear conditioning. Biological Psychiatry, 60(4), 361 368. Hermans, D., Dirikx, T., Vansteenwegenin, D., Baeyens, F., Van den Bergh, O., & Eelen, B. (2005). Reinstatement of fear responses in human aversive conditioning. Behaviour, Research and Therapy, 43, 533 551. Howley, J., & Waters, A. M. (2017). Overt verbalization of strategies to attend to and retain learning about the threat conditioned stimulus reduces US expectancy generalization during extinction. Learning and Motivation, 59, 19 26. Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100. Kendall, P. C., & Hedtke, K. A. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual. Ardmore, PA: Workbook Publishing. Kendall, P. C., Hudson, J. L., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitivebehavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76, 282. Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 745 751.

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Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to reduce return of fear: A replication. Behaviour Research and Therapy, 38(1), 1 12. Lovibond, P. F., Davis, N. R., & O’Flaherty, A. S. (2000). Protection from extinction in human fear conditioning. Behaviour Research and Therapy, 38(10), 967 983. Magill, R. A., & Hall, K. G. (1990). A review of the contextual interference effect in motor skill acquisition. Human Movement Science, 9(3-5), 241 289. March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. Guilford Press. McGuire, J. F., Orr, S. P., Essoe, J. K. Y., McCracken, J. T., Storch, E. A., & Piacentini, J. (2016). Extinction learning in childhood anxiety disorders, obsessive compulsive disorder and post-traumatic stress disorder: Implications for treatment. Expert Review of Neurotherapeutics, 16, 1155 1174. Monfils, M. H., Cowansage, K. K., Klann, E., & LeDoux, J. E. (2009). Extinctionreconsolidation boundaries: Key to persistent attenuation of fear memories. Science, 324 (5929), 951 955. Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006). Mental reinstatement of context and return of fear in spider-fearful participants. Behavior Therapy, 37(1), 49 60. Niles, A. N., Mesri, B., Burklund, L. J., Lieberman, M. D., & Craske, M. G. (2013). Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia. Behaviour Research and Therapy, 51(10), 669 679. O’Malley, K. R., & Waters, A. M. (2018). Attention avoidance of the threat conditioned stimulus during extinction increases physiological arousal generalisation and retention. Behaviour Research and Therapy, 104, 51 61. Pediatric OCD Treatment Study. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292, 1969. Price, M., Tone, E. B., & Anderson, P. L. (2011). Vigilant and avoidant attention biases as predictors of response to cognitive behavioral therapy for social phobia. Depression and Anxiety, 28(4), 349 353. Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on fear reduction and return of fear. Behaviour Research and Therapy, 36, 719e734. Schiller, D., Monfils, M. H., Raio, C. M., Johnson, D. C., LeDoux, J. E., & Phelps, E. A. (2010). Preventing the return of fear in humans using reconsolidation update mechanisms. Nature, 463, 49 53. Sloan, T., & Telch, M. J. (2002). The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: An experimental investigation. Behaviour Research and Therapy, 40(3), 235 251. Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., & Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 469 478. Sy, J. T., Dixon, L. J., Lickel, J. J., Nelson, E. A., & Deacon, B. J. (2011). Failure to replicate the deleterious effects of safety behaviors in exposure therapy. Behaviour Research and Therapy, 49(5), 305 314. Treatment for Adolescents with Depression Study Team. (2003). Treatment for Adolescents with Depression Study (TADS): Rationale, design, and methods. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 531 542. Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., Van den Bergh, O., & Hermans, D. (2007). The repeated confrontation with videotapes of spiders in multiple contexts

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attenuates renewal of fear in spider-anxious students. Behaviour Research and Therapy, 45, 1169 1179. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., & Iyengar, S. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 2753 2766. Waters, A. M., & Craske, M. G. (2016). Towards a cognitive-learning formulation of youth anxiety: A narrative review of theory and evidence and implications for treatment. Clinical Psychology Review, 50, 50 66. Waters, A. M., Farrell, L. J., Zimmer-Gembeck, M. J., Milliner, E., Tiralongo, E., Donovan, C. L., & Ollendick, T. H. (2014). Augmenting one-session treatment of children’s specific phobias with attention training to positive stimuli. Behaviour Research and Therapy, 62, 107 119. Waters, A. M., & Kershaw, R. (2015). Direction of attention bias to threat relates to differences in fear acquisition and extinction in anxious children. Behaviour Research and Therapy, 64, 56 65. Waters, A. M., LeBeau, R. T., & Craske, M. G. (2017). Experimental psychopathology and clinical psychology: An integrative model to guide clinical science and practice. Psychopathology Review, 4(2), pr-038015. Waters, A. M., Kershaw, R., & Lipp, O. (2018). Multiple fear-related stimuli enhance physiological arousal during extinction and reduce physiological arousal to novel stimuli and the threat conditioned stimulus. Behaviour Research and Therapy, 106, 28 36. Waters, A. M., Mogg, K., & Bradley, B. P. (2012). Direction of threat attention bias predicts treatment outcome in anxious children receiving cognitive-behavioural therapy. Behaviour Research and Therapy, 50(6), 428 434. Waters, A. M., & Pine, D. S. (2016). Evaluating differences in Pavlovian fear acquisition and extinction as predictors of outcome from cognitive behavioural therapy for anxious children. Journal of Child Psychology And Psychiatry And Allied Disciplines, 57, 869 876. Waters, A. M., Potter, A., Jamesion, L., Bradley, B. P., & Mogg, K. (2015). Predictors of treatment outcomes in anxious children receiving group cognitive-behavioural therapy: Pretreatment attention bias to threat and emotional variability during exposure tasks. Behaviour Change, 32(3), 143 158. Westbrook, D., Kennerley, H., & Kirk, J. (2011). An introduction to cognitive behaviour therapy: Skills and applications. Sage Publications. Zbozinek, T. D., Holmes, E. A., & Craske, M. G. (2015). The effect of positive mood induction on reducing reinstatement fear: Relevance for long term outcomes of exposure therapy. Behaviour Research and Therapy, 71, 65 75.

Further reading Franklin, M. E., Sapyta, J., Freeman, J. B., Khanna, M., Compton, S., Almirall, D., & Foa, E. B. (2011). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. Journal of the American Medical Association, 306, 1224 1232. Vansteenwegen, D., Vervliet, B., Hermans, D., Beckers, T., Baeyens, F., & Eelen, P. (2006). Stronger renewal in human fear conditioning when tested with an acquisition retrieval cue than with an extinction retrieval cue. Behaviour, Research and Therapy, 44, 1717 1725. Vervliet, B., Craske, M. G., & Hermans, D. (2013). Fear extinction and relapse: State of the art. Annual Review of Clinical Psychology, 9, 215 248. Waters, A. M., Kershaw, R., & Lipp, O. V. (2018). Multiple fear related stimuli enhance physiological arousal during extinction and reduce physiological arousal to novel stimuli and the threat conditioned stimulus. Behaviour, Research and Therapy, 106, 28 36.

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C H A P T E R

4 Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy Tara S. Peris UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States

There is robust evidence to support the use of exposure-based cognitive-behavioral therapy (CBT) for the treatment of both child and adolescent obsessive compulsive disorder (OCD; Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016) and anxiety disorders (HigaMcMillan, Nakamura, Morris, Jackson, & Slavin, 2015). Although treatment protocols vary in their inclusion of/emphasis on cognitive coping, problem-solving, and relaxation skills training, they generally are unified in their emphasis on exposure practice. It is present in virtually every evidence-based protocol and typically viewed as the key ingredient for treatment success. Given its ubiquity, the question becomes when and how best to implement it. This, too, varies across protocols, with exposure tasks beginning early in treatment for some (e.g., in OCD treatment shortly after the initial assessment and psychoeducation are complete) or after an interval focused on teaching coping skills (as in anxiety disorders). In either case, all exposure practice is guided by a symptom hierarchy, which serves as a roadmap for treatment. In this chapter, we discuss strategies for developing a symptom hierarchy and for putting it to good use in treatment.

Exposure Therapy for Children with Anxiety and OCD DOI: https://doi.org/10.1016/B978-0-12-815915-6.00004-4

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Copyright © 2020 Elsevier Inc. All rights reserved.

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Evidence-based assessment to build a hierarchy At their core, fear and worry characterize both OCD and the anxiety disorders. However, symptoms of worry are heterogeneous, and can include cognitive (i.e., negative, fearful, ruminative, or threat-based thinking), psychophysiological (e.g., racing heart) and somatic (e.g., head and stomach aches) elements, along with hallmark indicators of behavioral avoidance. Thus, the content of fears and worries can vary considerably within and across children. It can be directed at family members to greater or less extent, affecting their behavior as well. Indeed, it is not uncommon for parents and siblings to provide frequent reassurance, participate in rituals or facilitate avoidance in an effort to reduce distress from symptoms (Calvocoressi et al., 1995; Lebowitz et al., 2013). Given this degree of variability in presentation, the first step in developing a symptom hierarchy begins with thorough assessment. Systematic, evidence-based approaches to assessment allow a complete view of each child or adolescent’s clinical presentation and they lay much of the groundwork for the hierarchy itself. Although approaches to assessment vary, the process should focus on gathering comprehensive information on both the history of the target symptoms and on the child’s current clinical presentation. It should also capture associated distress and impairment and comorbid conditions, as both may affect treatment process and outcome. Given that parents and children are likely to see things differently and that both reports offer information with unique clinical value (De Los Reyes, 2011), assessment should capture both perspectives wherever possible. To guide clinicians who may be less familiar with evidence-based assessment, in the next section, we briefly review the most widely used and well-established tools that clinicians might use in their assessment batteries. We also describe common self- and parent-reported symptom questionnaires for anxiety symptoms, anxiety-related impairment, and associated features of anxiety, recognizing their ease and utility in clinical practice. Although a plethora of options exist, we focus here on those that provide straightforward inventories that can be translated directly to a symptom hierarchy. For those interested in further information on this topic, a comprehensive discussion of assessment measures can be found in excellent work by our colleagues (see Silverman & Ollendick, 2005; Whiteside, Sattler, Hathaway, & Douglas, 2016).

Interviews and measures for the practicing clinician Because comorbidity is the norm in both pediatric anxiety and OCD (Peris et al., 2017), and because the presence of secondary conditions

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directly influences treatment outcome (Storch et al., 2008), we strongly encourage the use of established semi-structured diagnostic interviews as the cornerstone of youth assessment. Although many evidence-based interviews exist, the Anxiety Disorders Interview Schedule (ADIS; Silverman & Albano, 1996) is considered the gold standard. It remains the most widely used diagnostic tool in the pediatric anxiety research literature, and it is equally valuable in clinical practice to the extent that it identifies both OCD and anxiety disorders and the full spectrum of other youth psychopathology. The ADIS is structured to provide a module for each of the major Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) diagnoses, beginning with anxiety and other internalizing disorders. Each section begins with an initial prompt or query, after which the clinician is guided through follow-up questions as needed. Notably, the ADIS covers not only anxiety disorders, OCD, and panic/agoraphobia. It also contains modules for depression and externalizing disorders (attention deficit hyperactivity disorder (ADHD), Oppositional Defiant Disorder, Conduct Disorder), as well as screening sections for autism spectrum, substance abuse, psychotic, selective mutism, eating, somatoform, and learning disorders (based on DSM-5). The strength of the interview is that it is designed to be flexible for practicing clinicians. As such, it can be used with children ages 6 17 years, and can be administered to parents and children together or separately. This decision is, of course, guided by the age of the child, his or her preference in the interview, and clinician judgment. Regardless of the interview arrangement, the goal is to collect sufficient information to allow the clinician to make a final determination about whether the child meets the criteria for specific diagnoses. Within each section, respondents indicate whether specific symptoms are present or absent and, in some cases, offer 0 8 severity ratings for how severe specific fears or worries are. Along these lines, several modules have detailed symptom checklists that provide a thorough look at the symptoms found within a particular disorder. For example, the social phobia module includes a lengthy list of potentially anxiety-provoking situations, and it includes things like ordering food in a restaurant, speaking up for oneself when bullied, talking to strangers, and asking for help in class. These comprehensive checklists are useful for ensuring that nothing is overlooked, but they are particularly valuable for identifying useful targets for treatment (Rey, Marin, & Silverman, 2013). Indeed, they provide much of what is needed for an initial symptom hierarchy. Additionally, for each diagnosis, the clinician provides a “clinician severity rating” (CSR) that reflects the overall distress and/or functional impairment for each disorder based on a 0 (none) to 8 (very much) scale, with a score of 4 or higher indicating that the child meets diagnostic threshold for that disorder, and scores of 2 or 3 indicating borderline

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and elevated symptoms that are subthreshold for disorder, respectively. The CSR is derived from asking each reporter for his or her ratings of overall interference, and then using clinical judgment to determine a final score. The interview provides a “feelings thermometer” which is meant to be used as a visual tool to help children understand the concept of symptom severity. The CSR can be especially useful when children and adolescents meet for more than one diagnosis; in such cases, the highest CSR rating indicates primary disorder. This metric can also be useful when developing the hierarchy as it provides an initial indication of how challenging a given symptom (or cluster of symptoms) might be to address. The ADIS has well-established psychometric properties in several investigations, including strong inter-rater reliability (Silverman, Saavedra, & Pina, 2001) and fair concurrent validity (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). Importantly, it has also demonstrated sensitivity to clinical response in pediatric anxiety treatment trials (Walkup, Albano, & Piacentini, 2008). At the time of this writing, a newer version keyed to DSM-5 is nearing publication. The Pediatric Anxiety Rating Scale (PARS; RUPP, 2002) offers an alternative approach to assessment that is more squarely focused on anxiety symptoms. It is a dimensional, clinician-administered interview designed for use with children between the ages of 6 and 17. Unlike the ADIS, the PARS focuses on symptoms and related impairment that have been present in the past week. Thus, it offers a more immediate view of issues that may need to be addressed in exposure therapy. Although the PARS is not a diagnostic tool in the sense that it tracks symptoms according to DSM-5 criteria, it is a sound and reliable measure of anxiety symptom severity that is treatment sensitive and may be used to track symptoms over time. Moreover, its dimensional nature may provide a more sensitive estimate of anxiety severity than a simple indicator of presence versus absence of diagnosis. Based on these features, many clinicians use the ADIS and PARS in complementary fashion in clinical practice. The PARS includes a 50-item checklist that covers symptoms from the major anxiety domains (social phobia, separation anxiety, generalized anxiety, specific phobia), as well as somatic/physical symptoms. Guided by the interviewer, children and parents independently rate these symptoms as either present or absent in the last week, with the clinician providing a separate corresponding rating based on clinical judgment. The symptom checklist is a prelude to a series of 7 overarching severity items that assess the total number, frequency, and severity of symptoms along with the severity of physical symptoms, avoidance, interference at home, and interference outside of home. Each of these items is scored on a Likert-type scale, from none (0) to extreme (6),

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with a score of 3 on each of these scales indicating clinically significant levels of severity, avoidance, or interference. In each of these areas, the clinician again uses his or her clinical judgment to determine the final consensus rating for each of the severity items. The PARS total severity score reflects the sum of the global severity items that conclude the interview. Clinicians vary in whether they choose to include all 7 items in scoring or whether they exclude select items that may be subject to reporter bias. In particular, the item focused on total number of symptoms is often excluded from the total score, given concerns about the accuracy and reliability of reports from among anxious youth on this item. Likewise, the item rating severity of physical symptoms is also excluded in cases where youngsters are engaged in pharmacotherapy as part of their treatment because of potential physical side effects confounding reports about physical symptoms of anxiety (RUPP, 2002). Thus, in the extant literature, there are scores reflecting the omission of 1 item (total number of symptoms; Walkup et al., 2008) or 2 (total number of symptoms and physical symptoms; Johnco et al., 2015), both of which are highly correlated with anxiety severity. A cutoff score of 17.5 using a 7-item total severity score and 11.5 using a 5-item (excluding items 1 and 2) severity score has been found to distinguish between clinically anxious and non-anxious control youth (Ginsburg, Keeton, Drazdowski, & Riddle, 2011). In practice, if a clinician should pick a method and stick with it, ensuring consistency across visits and benchmarking across these two clinical cutoffs as appropriate. For purposes of constructing and refining a symptom hierarchy, the checklist that begins the interview may be particularly useful for generating symptoms on which to work, whereas the summary items may be used to adjust priorities over time as the drivers of frequency, severity, distress, and so on, change during treatment. The PARS has been used in several large-scale studies and has sound psychometric properties, including high inter-rater reliability, sufficient test retest reliability, and fair internal consistency and convergent and divergent validity (RUPP, 2002). Moreover, two investigations have examined the sensitivity of PARS total scores to treatment response, with implications for clinical practice. Caporino and colleagues examined PARS (6-item score excluding item 1) change over the course of treatment in the CAMS trial (Walkup et al., 2008), the largest child anxiety treatment trial to date, finding that a 50% PARS reduction and a total posttreatment severity score of 8 10 indicated diagnostic remission (Caporino et al., 2013). Johnco and colleagues also examined PARS change in a smaller trial of computer-assisted CBT for child anxiety, finding that a 20% reduction for the 5-item PARS and a 30 35% reduction for the 6-item PARS, and total posttreatment scores of 9 (for 5-item PARS) and 11 12 (for 6 item), indicated diagnostic remission (Johnco et al., 2015).

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Although findings from these two studies vary somewhat, pointing to different cutoffs for identifying remission, they both speak to the PARS as a useful tool in clinical practice.

Youth and parent report of symptom severity and impairment in anxiety and OCD Parent and child self-report measures of anxiety and OCD symptoms can provide a valuable complement to semi-structured diagnostic interviews and clinician-rated measures. These self-administered questionnaires offer ease, efficiency, and cost-effectiveness, and in some cases, they can serve as a screening tool when symptoms are suspected, but the need for a full diagnostic interview is unclear. Additionally, selfand parent-reports may be administered more frequently (i.e., every few weeks throughout treatment for clinical monitoring) than the above-described clinician-rated tools, and can be included with ease at the start or end of a session to track progress. For more information on self-report form options, we encourage readers to consult detailed reviews of the topic (see Connolly, Suarez, & Sylvester, 2011; Peris & Rozenman, 2019; Silverman & Ollendick, 2005). When selecting self-report forms, particularly those that will translate directly into treatment, we encourage clinicians to consider several characteristics associated with OCD and anxiety in youth that are important to assess and address in treatment. For example, anxious youth often report experience of somatic complaints (Kristensen, Oerbeck, & Torgersen, 2014), such as headaches and stomach aches, even if they do not relate these somatic experiences to their anxiety symptoms. Anxious youth also tend to interpret threat from environmental ambiguity (Creswell, Schniering, & Rapee, 2005) and set avoidant goals in response to situations in which they perceive a threat (Barrett, Rapee, Dadds, & Ryan, 1996). Additionally, anxious youth have difficulty tolerating uncertainty (Comer et al., 2009), which may in part account for their selection of avoidance as a strategy to manage their fears/worries. Finally, beyond the symptoms themselves, assessment should always carefully consider the impact they have on day-to-day functioning through a direct evaluation of functional impairment. The following measures, by no means the only available, are among the most common tools for assessing both symptom severity and functional impairment in youth anxiety and OCD. The Children’s Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) is a semi-structured, 10-item, clinician-rated measure of OCD severity with well-established psychometric properties. The instrument is designed to begin with an assessment of the presence or

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absence of OCD symptoms, capturing both the last week and lifetime history. It covers the full spectrum of OC symptomatology, including contamination, checking, symmetry/arranging, sexual, and religiosityrelated symptoms. Following the assessment of the presence or absence of individual symptoms, clinicians provide global ratings across several dimensions, including time spent each day, interference, distress, resistance of symptoms, and ability to control them. As with the ADIS, a chief benefit of this assessment approach is that it captures the full range of symptoms while simultaneously identifying clear treatment targets for a symptom hierarchy. Child Obsessive Compulsive Impact Scale Revised (COIS-R; Piacentini, Peris, Bergman, Chang, & Jaffer, 2007) is a measure of OCD-specific functional impairment. It is designed to capture the many ways in which OCD can interfere in a youngster’s life, and it has parallel parent and child versions. The parent version measures impairment in Daily Living Skills, School, Social, and Family domains. The youth report measures impairment in the following three domains: School, Social, and Activities. Subscales on both measures demonstrate strong psychometrics including good test retest reliability. The Family Accommodation Scale (FAS; Calvocoressi et al., 1999) is a 13item semi-structured clinical interview that assesses the degree to which relatives of people with OCD have participated in or facilitated patient rituals over the preceding month. The FAS measures both the behavioral involvement of family members in a child’s OCD (e.g., modification of daily routines, participation in rituals) and the level of family distress and disruption associated with this involvement via four subscales: Modification of Routines (5 items), Participation in Rituals (4 items), Informant Distress Associated With Accommodating (1 item), and the target child’s reaction (Consequences) to family attempts to refrain from accommodation. Individual items are rated on a 5-point Likert-type scale ranging from 0 to 4. Although designed to be used as a clinical interview, the FAS has successfully been used as a self-report form. Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997). The SCARED is a self-report questionnaire that has been used for decades in a variety of clinical and research settings. Historically, it assesses anxiety symptoms over the prior 3 months; however, this time frame has been modified without concern, speaking to its utility (Caporino et al., 2017). There are several versions of the SCARED, including 66- and 41-item versions that link symptoms to major DSM-IV categories as well as a brief 5-item screen; there are also parallel parent and child versions and several studies documenting treatment sensitivity. It has been normed on diverse samples and has consistently evidenced strong psychometric properties, including internal consistency and retest reliability.

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Child Anxiety Impact Scale Parent/Child (CAIS-/CP; Langley et al., 2014). The CAIS measures anxiety-related impairment across multiple domains of functioning (e.g., social, school, home/family functioning) and offers parallel parent and child-report forms. Its development was spurred by the recognition that, although interference and impairment are central to how anxiety disorders are conceptualized and diagnosed, they are less frequently assessed or targeted in treatment. The CAIS-P has been used in large-scale treatment studies (Walkup et al., 2008), and has demonstrated good internal consistency, construct validity, and discriminant validity. It provides clearly identifiable treatment targets aimed at improving functional status. Family Accommodation Scale Anxiety (FASA; Lebowitz et al., 2013). Based on the FAS for OCD (Calvocoressi et al., 1999), the FASA includes items adapted for use across the entire spectrum of youth anxiety disorders. In keeping with its OCD counterpart, it assesses participation in symptoms, modification of routines, and distress associated with patterns of symptom accommodation. The FASA exhibits good internal consistency and convergent and discriminant validity, and it offers a useful tool for understanding potential aspects of family functioning/family response to symptoms that may need to be included in treatment.

Translating assessment into treatment Assessment is an ongoing process, and one that is revisited throughout the course of treatment as rapport is established, more information is gathered, and progress is made. Once the initial steps above are complete, the task at hand is to translate the symptoms that have been identified into a meaningful treatment plan. The symptom hierarchy serves as one way to organize this plan, by taking the symptoms identified during the assessment and prioritizing them into more/less immediate targets. Before symptoms can be placed upon a hierarchy of difficulty, however, it is important to devote time to understanding the role they serve for the individual child or adolescent. This may have direct consequences for how easy or difficult they will be to address. Beyond the obvious role of relieving distress, symptoms may serve important broader functions. In some cases, they may allow youth to avoid responsibilities that would normally be their own (e.g., chores, responsibilities). In other cases, they may enable special one-on-one time with a parent who provides reassurance or participates in rituals. In still other cases, they may distract from other difficulties at home (e.g., parental discord). Understanding these pieces is important for recognizing factors that may shape and maintain symptoms over time and for adequately addressing them in treatment. Because of this, careful functional

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analysis of symptoms is an important step in developing a successful symptom hierarchy. At the most basic level, functional analysis involves assessing the factors that precede and follow a given symptom. It allows the therapist to gather information on different types of reinforcement, and to help families consider the various factors that motivate behavior. What is going on just prior to handwashing? What happens just after a child says that she is scared? The answers to these types of questions allow clinicians to understand factors that serve to reinforce symptoms. For example, if a child who tells her parents that she feels scared gets both parents to stop what they are doing, sit with her, and cuddle her for reassurance, the “consequences” of her behavior may be very positive indeed. Alternatively, if a child feels the urge to handwash in a classroom setting in which he is often teased, his symptom may serve the function of escape from an unpleasant situation (in addition to relief from germ worries). As noted elsewhere (Bennett, Keller, & Walkup, 2013; Peris & Piacentini, 2016), behavior may be maintained by both positive reinforcement (the behavior itself is gratifying) and negative reinforcement (in that it provides relief from distress). Each of these elements points to a different treatment strategy (raising the “cost” of the behavior in the former situation, exposure strategies in the latter) that may influence where/how it is used on a symptom hierarchy. Probing these features in session might go something like this: T

You mentioned that Maya asks you a lot of questions to relieve her anxiety.

P

Yes, I’m the one she comes to when she’s worried.

T

Can you give me an example of what that looks like at home?

P

Sure, last night she started worrying about her health and about whether she might die. She asked if 10 year olds can have heart attacks. I said no, but it kept going from there.

T

So your answer didn’t make her feel much better.

P

It did for a moment but then she had more questions.

T

What was happening before she came to you? Was there something that sparked that particular worry?

P

Yes, we were listening to the radio and there was a piece on women and heart attack risk that got her going.

T

So the radio piece seemed to set her off?

P

In that case yes, but sometimes it’s watching the news.

T

Okay that’s helpful, we’re identifying some of the things that might trigger her anxiety. What happens when she asks you a question?

P

If we’re at home, she usually bursts through the door of my office, I stop what I’m doing, she sits in my lap and we talk it out.

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T

What happens when you “talk it out?”

P

Well, I stroke her hair or rub her back and just generally try to get her to calm down. I answer her questions, and we just kind of hang out one on one until she seems more relaxed. Sometimes, if it happens in the evening, we’ll be late for dinner or late to join the rest of the family. She usually gets out of setting the table or helping out, that’s for sure!

T

What happens when you go back out to everyone else?

In this example, a clear symptom target (seeking reassurance) has already been identified. The goal of this discussion is to get specific examples that might guide how the therapist develops exposure tasks and to understand, from a functional analytic perspective, the broader context in which the symptom occurs. In this example, the information provided by the parent might prompt the therapist to think about exposing Maya to specific antecedents that trigger anxiety (news reports) and also about removing some of the reinforcement that comes from one on one time for Maya and her parent. She might have Maya practice waiting at the door of the office rather than bursting in or even saving her questions for a time when her parent is available to talk. Alternatively, she could write them down in a journal or practice giving them to the other parent (so that the favored parent is removed from the process). As variations such as these are identified and explored, potential distress ratings can be assigned and the therapist can start to think about how to tackle this symptom from many different angles.

Introducing the hierarchy Once the initial phases of the assessment are complete, it is time to move symptoms onto a hierarchy. This process involves explaining to the child and adolescent what the hierarchy is and how/why you will use it. You might say something like this: “You’ve done a great job of answering all of my questions and helping me to understand the different things that have been hard for you lately. What we’re going to do now is create a list of your symptoms that we’ll use in treatment. We’ll put as many things as we can think of on the list, and for each one, we’ll come up with a rating to tell us how much it bothers you. Once we have our list, we can start to organize it into things that seem relatively easy, things that seem harder, and things that seem super hard. We’ll start with the small stuff and gradually work from there.”

This description helps to explain that the hierarchy will guide treatment and that exposures will begin with a task that is accessible and manageable. Although in practice, you may move around on the

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hierarchy practicing items “out of order,” this step helps the child to understand that you will have a language for conveying how easy/hard each task is and where you are in the process of tackling symptoms. Often, once you’ve described how the hierarchy works and why it’s there, you can begin a process of open brainstorming (“So what should we put on this list?”). If it stalls, or if it appears incomplete, the therapist can then review the relevant assessment materials, highlighting specific symptoms that have already been endorsed and transferring them to the list. For example, she might highlight the items that were endorsed on the CYBOCS or specific examples of family accommodation from the FASA. This collaborative dialogue can be a way for the therapist to understand which symptoms the child is most eager (or afraid) to address; it can be a helpful way of establishing buy-in and motivation inasmuch as it allows initial targets to be chosen together based on child readiness.

Establishing anchors Once a list has been developed, the next step is to assign ratings to each symptom that serve to order them from easiest to most difficult. There is no set way to do this, and the scale you choose can go from 1 to 10 or 1 to 100; it can involve no numbers at all and instead use colors (green to yellow to orange to red as a progression of intensity) or faces (smiling, neutral frowning). In each of these examples, a visual representation of the scale can be helpful, as you will be asking for ratings throughout the treatment process and referencing whatever scale you choose. The basic goal is to distinguish among various levels of difficulty using an approach that your patient can understand. This is intrinsically subjective, thus the frequently used term “subjective units of distress” or SUDS. The conversation might go something like this: “Okay, it looks like we have a pretty good list here. The next thing we need to do is figure out which things here are easier and which seem like they would be harder for you to do right now. You probably have a pretty good sense of that already, but for us to work together, I need to know, too. So for each item on the list, I’m going to ask you to give me a number that tells me how hard that thing would be for you right now. We can use this thermometer to help. You see that it goes from zero to ten and that the color fills in as the numbers increase? On this thermometer, zero means that something wouldn’t be hard for you at all. Ten means it would be so hard or scary it would be impossible. Do you understand? (child responds) Good! So let’s start here, zero to ten, how hard would it be for you to have your mom drop you off at choir practice and not stay with you the entire time?”

Historically, clinicians have used SUDS ratings both to order the items on their hierarchies and to track response within a given

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exposure practice session. With the latter, they would monitor for habituation by watching ratings drop roughly 50% within a given exercise (that is, from a child-reported difficulty rating of 8 to 4 over time). As noted elsewhere in this volume, there is debate as to whether habituation is necessary for clinical progress, and a growing trend toward using the ratings to track a patient’s willingness to practice a given task rather than a change in SUDS over time. The result is that most clinicians use the hierarchy to organize their approach to treatment and to get a global picture of the symptoms that they will need to tackle in treatment. Clinicians who are less familiar with the process of building a symptom hierarchy often wonder what to make of the ratings that their patients provide, and a common concern is whether children may be overreporting or underreporting their SUDS. Rather than worry about the accuracy of a particular rating, it may be more helpful to focus on simply developing a language that can be used to communicate about perceived difficulty and/or readiness to try a given task. In cases where a child uses only the extremes of the scale (e.g., everything is a 0 or a 10), it can be helpful to focus on the 10 s, and ask, “What would make this easier?” The corresponding answers can be used to flesh out the hierarchy further. Similarly, it is not uncommon to have nested hierarchies wherein one big symptom yields multiple “mini hierarchies” within it. For example, a child with OCD may have one highly impairing symptom related to toileting, and the therapist may find it helpful to create a hierarchy for gradually reducing the amount of toilet paper and a separate hierarchy for gradually reducing the amount of parent participation in toileting.

Getting creative with it What does the hierarchy itself look like? Certainly, the most straightforward approach is to create a chart that lists all symptoms and their corresponding ratings. Additional columns can be added to record ratings at subsequent intervals throughout treatment (e.g., every other week, monthly). However, it is often more engaging to bring the hierarchy to life by presenting it in a format that kids can more readily understand. With this in mind, many therapists present the hierarchy as a ladder, wherein each rung is numbered in ascending order. It is impossible to jump on to the top rung (i.e., the 10, or hardest task) from the floor, and this visual easily illustrates the concept of gradually working your way into more difficult territory. Other versions of this same

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general idea include climbing a mountain, pyramid, or hiking trail with different stops along the way. Yet another presentation might involve a bridge to some bigger goal (being able to do a sleepover, go to a restaurant, etc.). Finally, some versions of the hierarchy forego this linear presentation altogether and simply involve index cards. This recognizes that difficulty levels may change over time and that you may sometimes work out of order. It lends itself nicely to a game-playing format in which you pick cards at random or take turns dealing tasks. If at all possible, build on the interests of the patient (baseball, piano, dragons, etc.) and incorporate the theme into the depiction of the hierarchy. This builds rapport and furthers the effort to develop a language around symptoms and the distress associated with them.

Putting your hierarchy to use As noted elsewhere in this volume (see Vinograd & Craske), traditional approaches to exposure therapy encourage therapists to work in a stepwise fashion moving slowly up the symptom hierarchy one step at a time. Individual symptom targets are tackled in a stepwise fashion moving from easiest to most difficult as each item is mastered. These approaches are based on a model which views symptom improvement in exposure therapy as the result of learning new associations about feared stimuli that serve to extinguish prior fearful responses. Yet, as noted here and elsewhere, growing research on the mechanisms underlying exposure therapy has called this approach into question, highlighting that new learning actually competes with or inhibits prior fear learning during exposure (Craske et al., 2008). This inhibitory learning framework is supported by research suggesting that habituation within and between sessions is not linked to clinical response (cites). It has numerous implications for treatment, including those that pertain to how the symptom hierarchy is used in treatment. Instead of using the symptom hierarchy to guide a linear progression of exposure tasks, therapists and clients may view it as a tool for capturing the big-picture view of the symptoms that need to be addressed in treatment and for thinking about how tasks may be meaningfully combined across different treatment targets. Freed from the monotony of working on a single symptom until it is mastered, clinicians can jump around on the hierarchy moving back and forth between tasks that are easier and harder and working more creatively to target multiple symptoms at once (e.g., asking an adult for help while waiting for a parent who is late to pick up from the session—combing a social phobia target along with a separation anxiety target).

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Adjustments throughout treatment Even if the goal is no longer squarely focused on habituation, it can be helpful to return to the hierarchy throughout treatment to reassess how difficult the original tasks remain. In many cases, this process allows a winnowing of the list, as you see that certain items have been mastered and are no longer difficult. This can be very encouraging for patients, as it provides a process for monitoring their own progress and, hopefully, reminding them that exposure works. At the same time, it’s important to use judgment with this strategy. For many youth, the initial stages of treatment are slow and the process is more about learning to tolerate distress than tracking a change in their SUDS ratings. Dwelling on symptoms that appear to be the same week-to-week (in terms of distress ratings) may be demoralizing, and it may be useful to focus on their effort and on improvements in their functional impairment. There is no set interval at which ratings should be reviewed, and the decision should always be guided by what is most useful clinically. In conclusion, the symptom hierarchy is the mechanism by which evidence-based assessment gets translated into treatment. When well crafted, it serves as a roadmap for treatment and a valuable tool for communicating with patients about how they perceive particular symptoms and about what they feel ready to tackle with exposure. As with all therapy tools, it works best when implemented with flexibility and creativity that keep its guiding principles in place while tailoring its use to the individual child or adolescent.

References Barrett, P. M., Rapee, R. M., Dadds, M. M., & Ryan, S. M. (1996). Family enhancement of cognitive style in anxious and aggressive children. Journal of Abnormal Child Psychology, 24(2), 187 203. Available from https://doi.org/10.1007/BF01441484. Bennett, S. M., Keller, A. E., & Walkup, J. T. (2013). The future of tic disorder treatment. Annals of the New York Academy of Sciences, 1304(1), 32 39. Available from https://doi. org/10.1111/nyas.12296. Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The screen for child anxiety related emotional disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 545 553. Available from https://doi.org/10.1097/ 00004583-199704000-00018. Calvocoressi, L., Lewis, B., Harris, M., Trufan, S. J., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152(3), 441 443. Available from https://doi.org/10.1176/ ajp.152.3.441. Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., . . . Price, L. H. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument

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Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., . . . Leckman, J. F. (2013). Family accommodation in pediatric anxiety disorders. Depression and Anxiety, 30(1), 47 54. Available from https://doi.org/10.1002/da.21998. Peris, T. S., & Piacentini, J. (2016). Helping families manage childhood OCD: Decreasing conflict and increasing positive interaction. Oxford University Press. Peris, T.S., & Rozenman, M. (2019). Chapter 14—Assessment of pediatric anxiety. In S. N. Compton, M. A. Villabø, & H. Kristensen (Eds.), Pediatric anxiety disorders (pp. 301 316). doi:10.1016/B978-0-12-813004-9.00014-1 Peris, T. S., Rozenman, M., Bergman, R. L., Chang, S., O’Neill, J., & Piacentini, J. (2017). Developmental and clinical predictors of comorbidity for youth with obsessive compulsive disorder. Journal of Psychiatric Research, 93, 72 78. Available from https://doi.org/ 10.1016/j.jpsychires.2017.05.002. Piacentini, J., Peris, T. S., Bergman, R. L., Chang, S., & Jaffer, M. (2007). Brief report: Functional impairment in childhood OCD: Development and psychometrics properties of the Child Obsessive-Compulsive Impact Scale-Revised (COIS-R). Journal of Clinical Child & Adolescent Psychology, 36(4), 645 653. Available from https://doi.org/10.1080/ 15374410701662790. Research Units on Pediatric Psychopharmacology Anxiety Study Group, On, U., Psychopharmacology, P., & Study, A. (2002). The Pediatric Anxiety Rating Scale (PARS): Development and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9), 1061 1069. Available from https://doi.org/ 10.1097/00004583-200209000-00006. Rey, Y., Marin, C. E., & Silverman, W. K. (2013). Assessment of anxiety disorders: Categorical and dimensional perspectives. Pediatric Anxiety Disorders, 231 267. Available from https://doi.org/10.1007/978-1-4614-6599-7_12. Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., . . . Leckman, J. F. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36(6), 844 852. Available from https://doi.org/10.1097/00004583-199706000-00023. Silverman, W., & Albano, A. (1996). The Anxiety Disorders Interview Schedule for Children IV (Child and Parent versions). San Antonio, TX: Psychological Corporation. Silverman, W., Saavedra, L., & Pina, A. (2001). Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent versions. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 937 944. Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 380 411. Available from https://doi.org/10.1207/s15374424jccp3403_2. Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., . . . Goodman, W. K. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47(5), 583 592. Available from https://doi.org/10.1097/ CHI.0b013e31816774b1. Walkup, J., Albano, A., & Piacentini, J. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medcine, 359, 2753 2766. Whiteside, S. P. H., Sattler, A. F., Hathaway, J., & Douglas, K. V. (2016). Use of evidencebased assessment for childhood anxiety disorders in community practice. Journal of Anxiety Disorders, 39, 65 70. Available from https://doi.org/org/10.1016/ j.janxdis.2016.02.008. Wood, J. J., Piacentini, J. C., Bergman, R. L., McCracken, J., & Barrios, V. (2002). Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent versions. Journal of Clinical Child and Adolescent Psychology, 53 (31), 335 342. Available from https://doi.org/10.1207/S15374424JCCP3103_05.

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C H A P T E R

5 Developing and implementing successful exposure-based interventions Dean McKay Department of Psychology, Fordham University, Bronx, NY, United States

Exposure-based interventions form the basis of comprehensive programs of cognitive-behavior therapy (CBT) for youth with anxiety disorders. There has been extensive research on the efficacy of CBT, and in controlled research compared to wait-list or attention control groups show large effects and small to medium effects when compared to credible alternative interventions (Crowe & McKay, 2017). The benefits of CBT and exposure are fairly consistent across ages in youth (Bennett et al., 2013). In research isolating the benefits of exposure in childhood anxiety disorders, meta-analyses have documented large effect sizes across conditions (discussed in Garner, Steinberg, & McKay, in press). This chapter focuses on the clinical implementation of exposure. Interested readers can review the theoretical and conceptual foundations in sources such as Abramowitz, Deacon, and Whiteside (2010) and McNally (2007). The aim of this chapter is to describe the basic mechanics of developing a sound treatment plan involving exposure therapy for youth with anxiety disorders. This includes (1) identifying the target stimuli for exposure, (2) developing the hierarchy, and (3) developing and implementing exposure based on the hierarchy. Also included will be common challenges that emerge in conducting exposure, including engaging family members in the course of exposure, problems in identifying in vivo situations for exposure, and complex anxiety presentations. In order to make these aims maximally useful, the majority of the

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chapter is in the context of an illustrative, seemingly straightforward but actually complex, phobic reaction, namely fear of vomiting (emetophobia). This phobia has a small research based, but is associated with comorbid anxiety and depression (Sykes, Boschen, & Conlon, 2016; Wu et al., 2017). A recent wait-list treatment trial showed that CBT, which prominently featured exposure, was efficacious in alleviating fear of vomiting in N 5 24 adults with emetophobia (Riddle-Walker et al., 2016). Published cases have illustrated the utility of exposure for emetophobia in children (Graziano, Callueng, & Geffken, 2010) and adolescents (Fix, Proctor, & Gray, 2016). As will be shown, emetophobia can be clinically complicated, with a wide range of stimuli that could lead to avoidance behaviors. Accordingly, emetophobia makes an ideal illustrative phobia for depicting methods of developing and implementing exposure procedures.

Basic illustrative case For the purposes of this chapter, the following case will be used in developing the means for identifying target stimuli for exposure, developing the hierarchy of stimuli, and for crafting and implementing exposure exercises, as well as for how to address complex issues that may arise in the conduct of treatment. Several important details about the child and family have been altered to protect their identities. The child, Trevor, age 14, was a normally developing male in the ninth grade. He lives in a suburban area, was born originally in a country other than the United States, and was adopted by a same-sex couple. He has a younger sister, age 11, who was also adopted. Aside from normal sibling disagreements, there is minimal family discord. Academically, Trevor is in advanced classes and is generally competitive in school. He has what he refers to as “four really close friends” and until he began to experience symptoms of emetophobia, he regularly socialized with friends on the weekend. Also prior to the emergence of symptoms, Trevor was involved in after-school sports, specifically soccer and baseball. His parents, Steven and Sam, reported that Trevor began avoiding social situations about 5 months prior to seeking treatment. At first, they attributed his sudden reticence to spend time with friends to emerging preteen moodiness and thought it would simply pass. However, shortly after his social withdrawal began, he also started to protest before going to soccer practice. When asked what he was concerned about, he would not report, only complaining that he “didn’t feel well” or “was tired.” The event that precipitated the call seeking consultation was when Trevor began showing resistance to attending school, asking on several occasions if he could be home schooled. When

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asked why he no longer wished to attend his current school, he said “the kids there are dumb” and “I don’t like the food in the cafeteria, I like the food at home better.” During this period of time, Trevor also began restricting his food intake. Before his social withdrawal began, he had a highly varied diet, including a wide range of spicy and rich foods, and enjoyed going to restaurants with his family. Shortly after the beginning of his social withdrawal, he also began rejecting different foods, especially spicy foods, and by the time he came for the initial appointment, he was only eating bland food (dry cereal at breakfast, turkey or roast beef at lunch with no seasoning, chicken nuggets and dry pasta at dinner). He would “inspect” his food for possible seasonings, and rejected any that had marks on it that he construed as pepper or other spices. About once a week this led to his skipping lunch because he found an offending mark on his food. He began to lose weight, and resisted going to restaurants, complaining “I don’t know if I’ll feel ok after the meal.” His parents brought him to their pediatrician, who medically cleared him. The pediatrician recommended psychological treatment, leading to his referral for therapy.

Determining the presence of phobia When Trevor arrived for the initial appointment, he was wellgroomed, polite, and appeared eager to discuss his concerns. He complained that he worried a lot about food and that he was especially fearful of getting sick while away from his house. The interview then delved into what his concerns centered on around being sick away from home, and ultimately it was determined that he was concerned with vomiting. Upon further questioning, his fear of vomiting centered on two major domains—being embarrassed if he vomited in front of others, and the adverse physical experience associated with vomiting. He reported that he was fearful that spicy food increased his risk of vomiting, and that new foods were a problem since he did not know whether he would be able to tolerate it. When asked when Trevor began to be concerned with vomiting, he reported that he was at a party on a weekend with friends. The child who hosted the party had an older brother (age 17) who also had friends over, and they offered alcoholic drinks to Trevor and his friends. He declined, but two of his friends drank a lot and one became sick. He then overheard his friend vomiting in the bathroom, and several other teens at the party began laughing, mocking Trevor’s friend for “not holding his liquor” and “being a lightweight.” Trevor reported that being mocked as a result of getting sick did not bother his friend. However, Trevor began to envision how he would have handled it had

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he been sick at a party. He also reported that when he overheard his friend vomiting, he felt strong nausea and briefly thought he, too, would vomit from the sound.

Key symptoms and genesis of feared situations Reviewing the presenting symptoms of Trevor, some crucial elements become evident. His phobic reactions emerged from a range of observational experiences (alcohol consumption, a friend vomiting, social discomfort resulting from vomiting) and associated physical sensations (nausea). Notice that Trevor did not vomit, but instead was sensitized to the possibility of something akin to this happening to him in the future. It would be tempting to adopt a purely cognitive approach given the preponderance of future-oriented catastrophic cognitions (see e.g., Clark & Beck, 2011). However, in light of the avoidance that was evident when Trevor initiated treatment, and the rapid generalization of feared situations, exposure was a suitable treatment plan.1 Further, theoretical perspectives support the concept of developing phobias without direct experience with the feared stimuli (i.e., the nonassociative account of phobias; Poulton & Menzies, 2002).

Identifying target stimuli From the briefcase description and presenting feared situations, there are several domains that are target rich for exposure interventions. First, there are sounds and potentially visualizations of vomiting. Trevor reported the initial learning situation for his fear emerged when hearing his friend become ill, and so this is likely to prompt considerable anxiety when presented. Second, social situations, particularly when he might experience gastrointestinal discomfort. Trevor reported that his friend was mocked for being sick, and following this Trevor worried that he would struggle to cope with experiencing what he perceived as social rejection should he be in a similar situation. And finally, there are a variety of foods that he previously enjoyed. This anticipatory anxiety Trevor reported stems from a generalization of his fear based on the expectation that vomiting would be more likely with certain 1 It is worth highlighting that cognitive interventions routinely include some form of exposure, such as through behavioral experiments. The anticipated outcome of these experiments are to elicit dysfunctional beliefs that would be subject to disputation (Bennett-Levy et al., 2004), but these also serve the purpose of habituation (Abramowitz, Taylor, & McKay, 2005).

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foods, or would be particularly aversive if he was sick following consumption of these food items. Once these broad categories of potential exposure stimuli are determined, the onus is on the clinician to occupy the mental and emotional world of the client to envision all the ways in which the world can be threatening as a consequence of the fear. This means that in order to really conduct effective exposure therapy, a basic phenomenological approach has to be adopted, whereby the clinician identifies the basic elements of the shared experiences that can connect with the client (see Kaufer & Chemero, 2015 for a discussion of phenomenological approaches). Therefore, before even beginning to develop the hierarchy, the clinician needs to begin formulating a series of hypotheses about potential components of each feared situation that could form the basis of the hierarchy (see “Developing the hierarchy—it is a phenomenological exercise” section for detailed guidance on the process of formulating these hypotheses). For example, consider the sounds and visualizations of vomiting. This can be broken down into mild gurgling sounds that precede vomiting; quick spitting up, such as what might be typical for infants; someone quietly spitting up food, all the way up to intense violent vomiting. This is broadly described as a stimulus complex, and it is crucial that clinician consider this throughout the course of exposure therapy. Fig. 5.1 illustrates the stimulus categories and smaller units in the stimulus complex for the three broad domains in Trevor’s case.

Vomit sounds

Emetophobia stimuli

Potential hierarchy items: Retching sounds “wet” noises making impact with floor “Toilet splash”

Social situations

Attending a party (alcohol may be present) Being around intoxicated people Hearing someone being mocked

Highly seasoned foods

Spicy food odors Tasting mildly seasoned food Feeling spiciness in the mouth

FIGURE 5.1 Categories of stimulus complexes in the case of Trevor.

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Developing the hierarchy Formulating the hierarchy is essential in crafting a series of potential exposure situations that can be practiced in the course of therapy. It is useful for both the clinician and child as the hierarchy sets up incremental steps for success that can be marked off as indicators of progress. It also allows for identifying starting points for treatment that can be reasonably managed by the child. This is in line with the classic principles of behavior therapy (Wolpe, 1990) and with the underlying basis for ensuring adequate therapeutic processing of fear provoked in therapy (Foa & Kozak, 1986).

Setting up the subjective units of distress Now that the stimuli situations have been identified, the hierarchy can be developed. In the case of Trevor, the clinician should start by providing him with anchor points for rating his distress level, referred to as subjective units of distress (SUDS). This means that the clinician will be asking about any emotional distress prompted by the stimuli, rather than merely fear. The following brief exchange between the clinician and Trevor illustrate this phase of the hierarchy development: Clinician (C)

Ok Trevor, so before we start, let’s develop a scale that you can use to rate how uncomfortable or distressed different situations may be. Can you describe a time that you might feel the most comfort or the most relaxed?

Trevor (T)

Well, I’m not relaxed too much.

C

Ok, well before you began being concerned about vomiting, do you recall when you felt the most relaxed?

T

I guess when I would go to sleep at night.

C

Ok, great, so on our scale, let’s call that a 0. That is the lowest level on the scale, meaning that we want to aim for that in our work together. Now, tell me a time when you felt the most distress, more than anytime before.

T

I think when I heard Oscar throw up when we were at the party that night. I felt really panicked when that happened.

C

Ok, so let’s call that 100 on our scale. So the lowest rating is 0, which is like when you would fall asleep before any of this started, and 100 is when you heard Oscar vomiting.

When developing the SUDS scale with younger children, it may be necessary to rely on nonnumerical anchor points. A popular method may involve a thermometer, where greater distress is “warmer” or “hotter.” Alternatively, some children may prefer to associate distress using

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100

0

High distress

Great white shark; high distress

Low distress Goldfish; low distress

FIGURE 5.2 Subjective units of distress scales—illustrative anchoring systems.

different animals, such as sweet docile animals for lower levels (i.e., kittens, puppies) and more predatory animals at the higher end (i.e., lions, wolves). One child recently treated by this author found different levels of tropical fish appealing, as he was fond of household aquariums. Fig. 5.2 illustrates three different scaling approaches used with differing age range children (see Chapter 10: Exposure therapy for generalized anxiety disorder in children and adolescents for further discussion of conducting exposures with young children).

Developing the hierarchy—it is a phenomenological exercise How do you know what questions to ask in determining putative stimulus elements for the hierarchy? The notion of developing an ordered list of components of the stimulus complex seems a simple thing, but on close inspection, the task demands the clinician occupy the mindset of the client. A richer hierarchy demands that the clinician imagine a day in the life of the client, where the feared situation(s) might crop up at any moment. As a result, the clinician considers objects and situations that could be envisioned to provoke fear using

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their own imagination of what the client’s life is like. Phenomenological methodologists call this imaginative variation (Wertz, 2010). Although this method is part of ethnographic analyses, the point here is that clinicians must make informed guesses about possible stimuli that comprise the stimulus complex in crafting a hierarchy of items that can be used for exposure. Accordingly, let’s occupy the mindset of Trevor by asking this important series of questions—If one were Trevor, what would be difficult in getting around each day? What difficulties does he encounter from the moment he gets up in the morning to the moment he goes to sleep? Once clinicians begin thinking in this manner, it is possible to craft exposure exercises that will potently address the presenting problem. The added benefit is that by inquiring about a wide range of situations, the clinician can develop stronger rapport with the child since it will become evident that there is a greater understanding of the depth and breadth of the problem.

At last, hierarchy development Now that the SUDS has been established, with anchor points, and the clinician is oriented to taking the perspective of the child with her or his fears, the next step is to begin considering possible components of the stimulus complex for the hierarchy. Change begins with the hierarchy A common occurrence when constructing the hierarchy is that youth will overestimate the amount of distress that will be experienced for proposed stimuli that comprise the larger stimulus complex. Consider the following opening dialog with Trevor in developing the hierarchy: Clinician (C)

Using our scale that we developed earlier, think of how much distress you’d feel if you saw your friend vomiting?

Trevor (T)

Wow, that would be 100

C

Ok, now, what level of distress would you feel if you were vomiting?

T

That would be more than 100!

C

Well, I get that, but if 100 is our absolute highest, would the idea of you vomiting be 100?

T

Yes.

C

Ok, so let’s think about your friend vomiting. Want to give me a rating for that now?

T

Hmm, I guess that would be 85.

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An important task for the clinician throughout treatment is to change the client’s expectations around the feared/distressing stimuli. Here, merely by constructing the hierarchy, Trevor begins to experience new expectations. During the initial evaluation, Trevor’s thoughts around vomiting are largely binary. “Vomiting, and any ideas of vomiting, are horrible” would likely capture his prevailing thoughts. But, even at the start of developing the hierarchy, this binary cognitive experience begins to erode once faced with the task of rank ordering feared situations. Getting into the finer points Once the process of developing the hierarchy is under way, the clinician’s task is to get as full a picture as possible of stimuli that might provoke distress. It is also at this point a clinician might begin to anticipate potential exposure exercises that could be performed with the child. The following dialog illustrates the phenomenological mindset of the clinician, along with anticipating possible exposure exercises that might later be conducted with Trevor: Clinician (C)

So now that we have established some of the highest items on your hierarchy, let’s think of some other things. How would you rate seeing a video of an animal vomiting? , This was suggested because the clinician is aware that there are numerous videos online of animals vomiting .

Trevor (T)

I don’t think that would be so bad, maybe 40.

C

Ok, good. What about a video of a person vomiting, with the sound off? , Again, the clinician is aware there are numerous videos online of people vomiting .

T

With the sound off, I think that would be 50.

C

So, coming back to the animals, what if the sound is off?

T

Oh, well, that would be 25.

C

And for a person vomiting, with the sound on, what would you rate that?

T

I think that would be 60.

C

Ok, and what if you were standing outside a bathroom door and you heard someone, but did not see them, vomiting? , This is in anticipation of a possible exposure exercise, to be discussed shortly .

T

I think that might be a 70.

It is worth keeping in mind the range of potential exposure exercises the clinician can carry out, or possible exercises that can be assigned,

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when constructing the hierarchy. This makes translation of the hierarchy into direct clinical application far easier. Involve all the senses Most people construe feared stimuli based on visualizations. Further, most clients report based on the things they see that prompts their anxiety. But the stimulus complex can influence all the senses. In order to produce rich and potent exposure exercises, the hierarchy should include other sensory aspects, as appropriate. Consider further the following dialogue with Trevor: Clinician (C)

Trevor, you are doing great. Now, how would you rate your distress if you entered a public bathroom and smelled vomit, but no one was there actually vomiting? , The clinician is anticipating a potential exposure exercise with this inquiry, to be discussed below .

Trevor (T)

Ugh, that happened last week. I guess it would be about 65.

C

I see. Ok, so now, how much distress would you feel if you burped and felt a little bit of food pop up into your mouth?

T

Oh, you mean a ‘verp’, a vomit-burp. Yes, I’ve had those. I think that would be a 70.

Table 5.1 displays Trevor’s hierarchy, and includes additional stimuli that were assessed for distress that cover other situations where the risk of encountering vomit was high, or where the risk he might feel nausea was high.

Developing and implementing exposure exercises Once the hierarchy has been constructed, it is time to begin exposures with the child. It is at this point that the clinician needs to keep in mind that the hierarchy will be subject to constant change throughout the course of therapy. There are several good reasons for this. First, the hierarchy should change, as mastery of different items on the hierarchy is established, the other ones should also get easier to manage. Second, children often overestimate the distress they will experience. Recall that Trevor had a binary assessment of anticipated distress when the hierarchy was started, which changed as the clinician guided him in estimating his distress for different situations. This shift often happens during exposure as well as during the construction of the hierarchy. Third, as exposure proceeds, new aspects

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TABLE 5.1

Illustrative hierarchy for Trevor.

Stimuli or situation

SUDS (0 100)

Video of animals vomiting, no sound

25

Video of animals vomiting, sound on

40

Enter public bathroom, no vomit smell

45

Eat a favorite savory food item, with small amount of pepper

50

Video of human vomiting, no sound

50

Eating mildly spicy food (i.e., barbecue chicken wings)

55

Going to dinner with parents, one or both parents order an alcoholic drink

60

Entering a public restroom, smell vomit

65

Experiencing a “vomit burp”

70

Standing outside bathroom, hear someone vomiting

70

See vomit on pavement, no odor

75

Standing in public bathroom, see someone immediately after they’ve vomited

80

See vomit on pavement, with odor

85

Sees friend vomiting

85

Client vomits

100

of the stimulus complex may become evident that were not anticipated by the clinician or reported by the child. An additional important standard clinicians should adopt is that the aim is for the child to leave the session the same or less anxious than when she or he arrived. This means that an ad hoc estimate of the rate of anxiety reduction will be made such that once exposure is initiated it can be predicted to subside within the time constraints of the session. As a result, the session should be carefully orchestrated, particularly at the beginning, so that exposure is begun early in the session with ample time for recovery. Finally, clinicians need to consider carefully the implicit messages they send to children when conducting exposure. Specifically, clinicians are advised to adopt a personal standard that they are willing to do whatever they ask of the child. Imagine how the clinician’s credibility would suffer if the following exchange took place with Trevor:

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Clinician (C)

Trevor, today it is time to practice making vomit sounds.

Trevor (T)

Ok, I should be able to do that. My friends do that all the time. I hate it, but I think I can do it.

C

Ok, well, I just want you to imagine it, don’t actually make the noise.

T

Um, it’s hard to visualize.

C

Um, well, ok, I guess we can get the sound for a vomit video, but I need you to put earphones in when you listen to it.

In this brief exchange, it is not subtle to see that the clinician is having difficulty with the necessary exercise. Clinicians do well to know themselves and what kind of exposure activities can be tolerated. To illustrate, this author once had a student who wanted to conduct exposure, but was also very concerned with dirt and germs. Needless to say, the prospect of this student conducting exposure for contamination fearful children with obsessive compulsive disorder was out of the question. When a therapist is unwilling or overly hesitant to engage in an exposure, the credibility of the therapist suffers and it sends conflicting signals to the youth. Specifically, while the therapist has expressed the importance of exposures to therapeutic success during psychoeducation, by expressing hestiancy (or avoidance) the therapist sends an unspoken signal that these same exposure exercises may be dangerous. The resolution of the aforementioned situation with the student in training was that she did not conduct exposure for contamination fear with the child, who was instead treated by the author, who has a very high threshold for contamination-based situations. Additional supervision time was devoted to reviewing the range of situations she would feel capable conducting exposure therapy without sending conflicting messages about danger. Ultimately she sought treatment for her own contamination concerns given her desire to be an effective cognitive-behavior therapist for anxiety disorders in youth. As of this writing she is a practicing psychologist treating anxiety disorders in youth, including those with contamination fears.

The first exposure exercise Imagine that you suffer from a severe fear, and the doctor tells you that treatment will involve gradually experiencing portions of that fear. Further, you’ve now spent a session talking about all the ways and dimensions that this fear manifests in your life. Then finally comes the day when the doctor wants to begin presenting these feared things to you. Sounds scary, right? And the danger is present that should the doctor proceed too quickly, particularly in the first session, that you

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will be too frightened to consider going back. Therefore, while exposure is an incredibly potent method of treatment, if done improperly can also be harmful (see Dimidjian & Hollon, 2010; for a discussion of how to evaluate harm in treatment). Indeed, in the seminal conceptualization of the process whereby exposure is effective, it was expressly pointed out that treatment should be sufficiently intense to promote change, but not so intense that the stimuli cannot be processed (Foa & Kozak, 1986). Should the threshold be passed where the exposure is not processed adequately, individuals can instead be sensitized further, worsening symptoms. What all this means is, rather than prompting anxiety in the clinician, that exposure works best when paced to meet the needs of the child (and parents as developmentally appropriate). So, clinicians should consider starting with the easiest items on the hierarchy first. Should the child find the experience very easy, the clinician can progress further up the hierarchy, gradually, and check frequently during the session to be sure the child is processing the exposure adequately. In this way, there is an essential dialectic for the clinician to keep in mind: maintain awareness of the pace for the child, but do not fall prey to the “spun-glass theory of mind” (Meehl, 1973), where the assumption is that the child is too delicate to tolerate the experiences. In the case of Trevor, the first exposure exercise would involve viewing an arrangement of videos of animals vomiting. Fortunately, in the era of YouTube, there is an abundance of such videos, ranging from common domesticated animals (i.e., dogs and cats) to exotic creatures (i.e., tapirs, gibbons). In preparing for the first exposure session with a child, some preparation is in order. So, in this case, identifying and selecting videos for use is necessary, including a pre-screening for appropriateness.

Therapist behavior during exposure While conducting exposure, there are two major approaches: in vivo (or live) exposure or in imagery. Each one in isolation has clear benefits. In vivo provides an ecologically valid presentation of stimuli that the child may encounter outside the clinician’s office. In imagery allows the clinician to construct stimuli that would not likely be encountered in everyday experiences, or would be difficult to develop as an officebased exercise. Research suggests, however, that the most effective method is to combine in vivo with imagery (see Abramowitz, Deacon, & Whiteside, 2019). One compelling reason for doing this is to address automatic cognitive processes of strategic avoidance (discussed in

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Foa & Kozak, 1986). To illustrate, consider Trevor’s behavior when first presented with a video of a gibbon vomiting: Clinician (C)

Trevor, we’ve been viewing this video for the past 45 seconds. How much distress do you feel?

Trevor (T)

Almost none.

C

Really? That’s surprising. How did you do that, when you expected to at least feel about a 25?

T

Well, while the animal is vomiting, I’m thinking about my favorite song.

As per Foa and Kozak (1986), strategic avoidance of the stimuli interferes with processing. Rather than sensitizing the child, however, it renders the exposure exercise useless. Consider now the adjustment the clinician makes after Trevor’s admission of strategic avoidance. Clinician (C)

Ok Trevor, so let’s watch the video again, but this time I’d like to discuss what we are watching.

Trevor (T)

Ok. , video starts on computer .

C

Wow, look at how that gibbon can vomit, very impressive! From the looks of what’s shooting out of his mouth, I’d say he had a heavy salad for lunch, maybe tomatoes too.

T

Seriously doc? That is really yucky (laughs a little).

C

Ooh, look now, he’s puking so hard I think an eyeball is going to shoot out. Imagine if an eye popped out and fell in his puke! That would make this a viral video I would think.

T

Haha, yeah, I might even share it on Instagram.

C

How much distress did you feel when I first spoke about the gibbons’ heavy lunch?

T

It shot to about 30.

C

And what is it now?

T

Maybe 15.

There are several things happening in this exchange. First, as noted previously, by compelling him into a social exchange with the therapist, Trevor’s strategic avoidance is blocked. Second, now that the therapist has Trevor’s attention, the intensity of the vomit imagery on the screen can be highlighted, and even expanded on for possible worse images to come in the scene. This is the imagery component, where something that

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is improbable can be involved in the exposure. The value of this is to develop in Trevor the capacity to tolerate stimuli more intense than the situation that sparked his avoidance in the first place. Third, the clinician created an imagery that was also disarming, and Trevor found this comical. By creating a scene that transformed an otherwise fear-provoking situation into one prompting humor, the expectations that Trevor holds for a portion of the stimulus complex is now altered. This approach of shifting expectations is consistent with the inhibitory learning conceptualization of exposure (see Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014; Frank & McKay, in, press, for discussions). Briefly, the inhibitory learning model posits that new learning occurs in exposure merely by completing the exercise. Should anxiety or distress occur (and reduce), this can be part of the processing, but is not essential.

Making the most of exposure Once in vivo exposure is started, the clinician’s aim is to maximize the outcomes that can be gained in a single session. As noted earlier, one of the most effective ways to accomplish this is to couple the in vivo exposure with imagery targeting the primary feared aspects of the phobia. Relying on the aforementioned phenomenological approach to developing hierarchies, during the in vivo exposure, the clinician is well-advised to consider the perspective on the activity being experienced by the child. What are the feared outcomes that the child is anticipating might yet occur? These anticipated outcomes should form the basis of the imagery. To illustrate, a route that was taken with Trevor later in treatment was to include social concerns around nausea. As Trevor mastered eating a wider range of foods with confidence, attention was shifted to social consequences of vomiting, particularly if at a party. This included the therapist making statements that mirrored the anticipated comments from peers, such as “what a lightweight!” and laughing during remarks of feeling nausea. When developing imagery exercises such as the ones noted here, it is important to inform parents of the content, such as in Trevor’s case where reference to alcohol in an underage minor was covered. Further, in order to be fully sensitive to the child and parent concerns, reliance on interventions such as laughter related to symptom expression should be highlighted as genuinely to prepare the child for possible real-life situations. Critically, when conducting a session of this sort, a debriefing immediately following the exercise is important to discuss how the exercise was tolerated, what coping strategies might be employed, and to emphasize the ways in which the child performed well.

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Between session exercises It is important to socialize the child and family to the need to practice exposure between sessions. This is done to promote additional distress reduction to the stimulus complex, and to foster generalization as the child will be practicing in settings other than the clinician’s office. It is at this point that it is also important to suggest ways that the parent can participate. There are several ways parents can assist in the exposure exercises: • Encourage the child to practice exposure • Reward the child for successfully engaging in the exposure exercises • Model behavior of the clinician to aid in preventing strategic avoidance Before proceeding, the clinician needs to gauge the parent’s disposition toward exposure. For example, do they engage in accommodating behavior? That is, do they do things that foster the avoidance? If so, what are the reasons for the accommodation? Accommodation is a recognized problem that interferes with treatment outcome in youth anxiety (i.e., Kagan, Peterman, Carper, & Kendall, 2016), and so this must be addressed as part of exposure treatment. Further, do parents endorse the “spun-glass theory of mind?” If so, this too could interfere with between-session exposure homework assignments. Treatment efficacy for anxiety disorders is best when homework compliance is high (i.e., Arendt, Thastum, & Hougaard, 2016). Alternatively, perhaps the avoidance is useful in addressing specific concerns that the parents have not fully addressed. To illustrate, Trevor’s parents both accommodated, and found that his avoidance served a purpose for them. They accommodated because they had difficulty tolerating observing their son in distress. As for the way avoidance served their own needs, since his emetophobia was sparked by an incident involving alcohol, his fear of vomiting allowed them to avoid their own worry about Trevor’s potential alcohol consumption. Successful treatment was predicated on not only Trevor’s participation in exposure, but in his parents getting past their concerns over observing their son in distress and their reticence over his exposure to alcohol.

Rewarding exposure Practicing exposure between sessions can be difficult. The child is doing it without the guidance of the therapist, and the prospect of doing something that by its very nature is anxiety provoking may likely be undesirable. Therefore, it will be necessary for there to be incentives.

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These incentives should be specifically programmed into treatment, and be developed in collaboration with the parents. Rewarding younger children Typically children under 12 respond well to declarative reward systems, such as ‘star charts’ where specific tasks are listed on a dayby-day basis, with stickers placed on the page each day for successfully completing the task. This chart should be displayed somewhere the child regularly sees it so she or he can observe their progress. At regular intervals (i.e., each day, 2 days, or weekly) the child can earn a small reward for accomplishing a proportion of the tasks on the chart. This should be discussed with the parent, and the reward should be scaled to the effort. That is, a week’s worth of effort should result in a reward that can be easily repeated week after week. This might mean a special trip for dessert, or a small prize (see Chapter 10: Exposure therapy for generalized anxiety disorder in children and adolescents for further discussion of conducting exposures with young children). Rewarding older children Preteens and teens may not appreciate the aforementioned star chart, viewing it as too juvenile or overly structured. The clinician developing a reward program for this age group would have to rely on judgment about the suitability, or simply ask the child if this is something they would find appealing. If not, then the progress would need to be tracked privately, and the child would earn some additional privilege, following consultation with the parents and child. This might mean additional “screen time” or other reward. It could also mean a similar, age-appropriate reward as with younger children, only without the public declarative illustration of progress. Of additional note for older children involves the social praise parents may deliver. Given the age-normative parent child tension present in teens, praise can work against a parent. As a 15-year-old female child said so eloquently to this author, “please ask my mom to not make the praise a, you know, punishment.” What she meant by this was the desire of the parent to hug or otherwise show positive response in ways that a much younger child might find pleasant but teens might find aversive. Between-session exposure assignments

As noted previously, exposure exercises should be developed for practice after each session. Near the end of each exposure session, the clinician should begin thinking of how the exercise practiced in session can be translated to a homework assignment. The assignment that is ultimately determined should be one easily practiced, repeatable, and

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relatively brief. These will help ensure that the child will in fact complete the assignment. In the example above with Trevor, the assignment was easily developed—he merely had to watch the same videos at home that were viewed in the office. As we will see, future assignments may require greater ingenuity on the part of the therapist. Moving up the hierarchy

At this point, what would likely be several sessions into a program of exposure treatment, the therapist can begin to move on to more advanced items on the hierarchy. As with earlier items, some careful planning may be necessary to orchestrate the exposure exercise in session, and an eye toward crafting between-session exercises. In our illustrative case, it was determined that addressing foodrelated concerns should be part of treatment relatively quickly. To do this, the therapist furnished several different food items for the session, and it was requested that Trevor arrive for this session hungry. In the prior session a list was developed of foods that he found palatable, but was reluctant to eat. In effect, a mini-hierarchy was developed for different foods that he was avoiding. The final set of foods Trevor was prepared to consider were: plain tortilla chips, barbecue potato chips, banana peppers (which are mildly spicy), and a Tabasco-flavored beef jerky. The following exchange took place: Clinician (C)

Trevor, which of these items would be easiest to try first?

Trevor (T)

The regular tortilla chips would be really easy, like no challenge at all.

C

Ok, so try a few now. ,Trevor eats two chips .

C

You look a little queasy. , This is to begin, right at the outset, to develop the kind of imagery that will continue to accompany the exposure for this exercise .

T

Haha doc.

C

How much distress do you feel?

T

Close to zero. Maybe a tiny bit when you said I looked sick.

C

Ok, which one should you try next?

T

I think the barbecue chips should be next.

C

Ok, before we start, how much distress do you expect these will cause?

T

I think it may be around 45.

C

Ok, go ahead. , Trevor eats one chip, slowly, biting only a small piece .

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C

I think you can bite off a bit more, what do you think?

T

Ok, I’ll give it a try.

C

Hmm, you look a little green. How’s your stomach doing? Churning lightly, or is it on the high-speed spin? , this was done to shift expectancies, in line with the aforementioned inhibitory learning model .

T

I’m doing fine. These are tasty.

C

So how much distress do you have?

T

I’m surprised. I feel fine.

C

Ok, so what do you think, you up for the banana pepper?

T

That one is going to be hard.

C

Remember, peppers have a lot of vitamins. , This comment is not just to make light banter. It is to continue to shift expectancies around otherwise feared stimuli .

T

Ok, I’ll try it. , proceeds to bite the pepper .

C

The last kid to come in here and eat a banana pepper vomited right away in my trash can. It took weeks to get the smell out of here.

T

You’re joking.

C

Do I look like I’m joking? Ok, how much distress are you feeling now?

T

Well, it’s not a lot. About 30.

C

That is great! You are doing so great with this! See if you can take a few more bites of the pepper.

T

Ok. ,Proceeds to finish the pepper .

C

Great job! Too bad you’re going to barf all over my office. Good thing I see my next appointments down the hall.

T

Haha, that’s funny.

C

Trevor, you’ve been doing great today, really great! I’m so proud of you. Ok, now, are you ready for the hardest item of the day, the spicy beef jerky?

T

Um, ok.

C

Before we do this, how does your stomach feel?

T

So far I’m fine.

C

Ok, good. Let’s try the last item.

T

Ok, here we go.

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, Takes a bit of the beef jerky . T

That is really spicy. I didn’t expect that.

C

How much distress do you feel?

T

I’m at about 70.

C

Ok, focus on the sensation, and let me know when it goes down. , The pause in more intense imagery was to ensure that Trevor does not experience so much distress that he fails to process the exposure task. However, note that the clinician requests that he remain focused on the sensations, so as to still curtail any effort to strategically avoid the situation..

T

I’m at about 50 now.

C

Great! Can you take another bite?

T

Ok.

At the conclusion of this exposure exercise, Trevor finished the beef jerky and his SUDS rating was below 30 by the conclusion of the session. The between-session homework assignments were to eat one to two spicy items each day. A list was constructed of different spicy items he could try, some that were the same as those tried in the office, and some that he had not tried during the session. This was done to specifically foster great generalization of the gains he made in the session.

Barriers to successful exposure therapy The case illustration here was close to an “ideal” case. Trevor was motivated, his parents were able to easily address their concerns that might have otherwise interfered with between-session treatment compliance, and Trevor responded well to exposure exercises within sessions. Further, Trevor had good rapport with the therapist, and ultimately most of the items on the hierarchy were accomplished. At one point near the end of treatment, Trevor developed a stomach illness and vomited, with no set back in his treatment trajectory. Of course, cases do not typically go as smoothly as Trevor’s. Indeed, there are several hazards that clinicians need to be wary of when beginning exposure therapy with youth. McKay, Arocho, and Brand (2014) outlined several ways in which treatment may go awry when implementing CBT for anxiety disorders.

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Therapist factors Underappreciated in CBT broadly, and exposure in particular, is the role of therapeutic alliance. Failure to adequately develop a solid alliance with the child and family is a formula for poor outcome. On momentary reflection, the role of alliance becomes clearly salient when conducting exposure. The therapist is asking the client to trust them as they together begin confronting fear-provoking stimuli. Both parties must have a clear common goal in order for this therapeutic relationship to be successful. Research has borne this out, with alliance associated with lower dropout and better treatment outcome (Westra, Constantino, Arkowitz, & Dozois, 2011). Additional barriers to good outcomes involve a confluence of conceptualization errors, such as inadequately developed hierarchy, slavish adherence to protocol, and/or insufficiently developed case conceptualization (discussed in McKay et al., 2014). A well-developed case conceptualization, covering the critical variables involved in the clinical presentation, such as the ones discussed above from both the child and the parents, and both following and refining this conceptualization as treatment progresses, provides the clinician with a guide to keep treatment focused on the outcomes that would be expected to procure symptom relief, improve functioning, and reduce the risk of relapse following treatment termination (see Tolin, 2016). Clinicians that are most effective at implementing exposure have also either dispelled, or have not previously endorsed, the spun-glass theory of mind. Clinicians need to fully embrace the underlying conceptual tenets of the procedure—that through repeated experiencing of harmless stimuli that are the source of fear new learning takes place and better emotional functioning accrues. The experimental evidence to show this is compelling. For example, Farrell, Kemp, Blakey, Meyer, and Deacon (2016) found that explicitly addressing therapist concerns about the perceived dangers of exposure greatly enhances their later ability to implement the intervention effectively. Whiteside, Deacon, Benito, and Stewart (2016) found that clinicians who hold positive views of the procedure generally are more effective at implementing exposure therapy for childhood anxiety disorders. Accordingly, clinicians who endeavor to offer exposure therapy are advised to carefully consider their own biases about child functioning and personal concerns over implementing a procedure that may produce distress. If there are residual concerns, proceeding with exposure therapy will be problematic and likely result in a poorer outcome. Finally, it has been noted that in some exposure exercises, the feared outcome is expected a long while after the procedure (discussed,

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for example, in the case of OCD in McKay, Storch, Nelson, Morales, & Moretz, 2009). When this is the case, exposure should be delivered more gradually, and preparation for a post-session stress reaction is warranted. Consider the following exchange that occurred with Trevor related to this point: Clinician (C)

Today we are going to work on eating more food, and also provoke some of the internal sensations that might make you feel nausea. Remember when we discussed this last week?

Trevor (T)

Yes, I remember. I’m kind of worried about this.

C

It’s ok, you’ve done great so far. I’m confident you’ll handle this beautifully.

T

I don’t know about that.

C

So we agreed last week that you would eat these spicy items that your parents brought to session. We have some very spicy foods here from what used to be your favorite Mexican restaurant. Burrito, refried beans, tortilla chips, and yellow rice. It looks and smells delicious! Ready?

T

I am hungry, but this is a lot of food.

C

Ok, just do your best. Remember all the things you’ve done well so far. , Proceeds to eat. Clinician just engages in chit-chat with Trevor about school, music, and recent movies. This is strategic, as it demonstrates that the clinician does not view any of this as a danger .

T

Ok, I think that is all I can eat. I ate a little over half of the food.

C

Great, you did fantastic! How much distress do you feel?

T

Not as much as I thought I would. I guess about 40.

C

Excellent. Ok, now, I want you to press, with your palm, on your stomach. Like this. . . (clinician demonstrates by pressing in firmly on his own abdomen six to eight times).

T

Um, won’t that make me want to barf?

C

It might. And that is the point. You might overeat someday, by accident, and I want you to be ready for it. ,Trevor presses on his abdomen .

C

How much distress do you feel now?

T

Um, not really more. Maybe 55.

C

Ok, now, here is the catch. You might feel stomach pain later. Think of all the things we’ve worked on. Are you ready to practice what we’ve worked on so far? What kind of things do you think would be worth doing if that happens?

T

I guess I can picture puking, like we did in the office.

C

Yes, that would be best. When we’ve done that before, in the office, how have you felt?

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T

I always laugh, or it feels less upsetting.

C

Ok, good. So keep that in mind if you feel distress about the things we did in the office today after our session is over.

This exchange is intended to prepare Trevor for the real possibility that the after effects of exposure will be sometime long after he leaves the office. This situation is relatively common across the anxiety disorders in children, particularly into preteen and teen years. This is largely due to the changes in cognitive development that permit prediction of actions as having consequences further into the future (discussed in Puliafico & Kendall, 2006). Preparing children for the possible “delayed stress reaction” as this author sometimes refers to it can diminish the possible adverse outcomes from this phenomenon.

Child factors In addition to the aforementioned clinician factors that could limit outcome, children arriving for treatment may present with complications that would serve as barriers to efficacious treatment outcome. As noted earlier, parental accommodation will limit therapeutic improvement and so clinicians need to incorporate methods for addressing these issues. Another salient factor in outcome is between session treatment adherence and homework compliance (Peris et al., 2017). Clinicians can manage this by ensuring there is low parental burden in assisting in between session exposure tasks, developing homework assignments that have low difficulty and high degree of likely success for the child (scaled to the child’s needs and progress in treatment), and that the assignments are brief and easily repeated. An additional clinical challenge involves children who may be less inclined to discuss the presence of fears with the clinician. These “silent sessions” can be extremely taxing for clinicians, particularly given the natural inclination to fill silent time with talk (discussed in Koudenburg, Postmes, & Gordijn, 2011). In preparation for these kinds of sessions, clinicians might consider preparing themselves by spending quiet time with a friend, such as playing a board game where neither party can speak, in a kind of “exposure for social silence.” When treating a child who is inclined to in-session silences, the clinician has to reorient to more “doing” than talking. This can result in constructing hierarchies based on prompts, such as presenting brief descriptions of items that are “best guesses” of low-level items to identify stimulus items that are a concern, and moving up from there. It may also require working with an incomplete hierarchy, focusing only on lower level items and gaining mastery, followed by developing the more demanding items later.

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Children who are less talkative require patience, and parents of such children will also need coaching to watch for improvements, however subtle, and provide reward for these small incremental observed gains.

Planning for termination Once treatment has addressed the hierarchy fully, with modifications made as needed through the discovery of additionally relevant stimuli in the course of treatment, then termination may be considered. When doing so, one or more session should be scheduled to prepare to prevent relapse. Interestingly, there is little systematic relapse prevention research in anxiety disorders generally, and child anxiety in particular. However, basic experimental lab research suggests that a key factor in the return of fear is when the original context in which it was learned is presented (i.e., Bouton, Mineka, & Barlow, 2001; Bouton & Schwartzentruber, 1991). In the relapse prevention sessions, then, clinicians can plan for this by encouraging exposure in situations that approximate the original learning situation, to the extent possible. An additional useful strategy is to schedule a “booster” session after treatment ends. This might be scheduled three to six months after the final session. The agenda for such sessions would be to review the status of the original presenting symptoms, and prescribe potential additional exposure exercises. If symptoms are largely remitted, no further sessions are necessary.

Conclusion Childhood anxiety disorders have been found to respond very well to exposure therapy. Although the basic premise of exposure seems simple, on close inspection, there are many important factors that must be considered before initiating the procedure. Clinicians need to personally embrace the approach, adopt a phenomenological perspective on the child’s symptoms, develop and continually refine the fear hierarchy, and creatively develop exercises to allow for engagement with the components of the stimulus complex. Engagement with parents and caregivers, in order that treatment may take place outside the session, is also essential for good outcome. Successfully implementing exposure therapy, and observing the reduction in symptoms that powerfully occur with the procedure, is a highly gratifying experience for clinicians. Indeed, it may be one of the methods that most reinforces clinicians’ typical personal reasons for pursuing a career in the helping professions—through a potent and often life-changing reduction in debilitating emotional challenges.

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C H A P T E R

6 Exposure therapy for childhood selective mutism: principles, practices, and procedures Jami M. Furr, Amanda L. Sanchez, Natalie Hong and Jonathan S. Comer Department of Psychology, Center for Children and Families, Florida International University, Miami, FL, United States

Selective mutism (SM) is a relatively rare but highly impairing anxiety disorder characterized by a persistent failure to speak in settings where speech and socialization are expected (e.g., school or in the community), despite a demonstrated ability to speak in other contexts (American Psychiatric Association, 2013). Although SM only affects roughly 1% of children (Bergman, Piacentini, & McCracken, 2002; Viana, Beidel, & Rabian, 2009), associated challenges negatively impact multiple domains of the child’s life, including social functioning, academic performance, and family relationships (Bergman et al., 2002; Muris & Ollendick, 2015; Viana et al., 2009). SM symptoms often have the most significant impact on the school environment, limiting the child’s ability to communicate effectively with teachers, staff, and/or peers, and compromising academic achievement (Kumpulainen, Ra¨sa¨nen, Raaska, & Somppi, 1998). Accordingly, effective intervention for childhood SM is critical. SM typically onsets in early childhood—between the ages of 2 and 5 (Cunningham, McHolm, & Boyle, 2006; Kristensen, 2000)—but the condition often goes undiagnosed until around age 5 at the beginning of kindergarten or first grade (Muris & Ollendick, 2015). Similar to other anxiety disorders, SM shows high rates of comorbidity, with social

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anxiety disorder and separation anxiety disorder among the most common co-occurring conditions (Kristensen, 2000). In addition, several studies indicate that approximately 20% of youth with SM also show co-occurring oppositional behavior problems (Kristensen, 2000; Steinhausen & Juzi, 1996). Genetic and environmental factors appear to contribute to the etiology of SM in youth. Research finds higher rates of psychopathology among the parents of children with SM versus among the parents of children without SM (Chavira, Shipon-Blum, Hitchcock, Cohan, & Stein, 2007). In one sample, Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, and Gutenbrunner (2001) found that 18% of mothers and 18% of siblings of youth with SM also had a history of SM themselves—and 51% of fathers and 44% of mothers showed general patterns of behavioral inhibition. In addition, although findings are mixed, higher rates of SM have been found in bilingual children (Toppelberg et al., 2005), with bilingual children in one sample showing nearly four times the rate of SM relative to monolingual children (Elizur & Perednik, 2003). Heightened inhibition in social settings and patterns of parental accommodation can foster negative cycles of avoidance that set the stage for reinforced patterns of nonverbal behavior over time. A number of factors have historically limited the extent of clinical and empirical attention afforded to SM and its treatment. In addition to the relative rarity of its presentation, the most appropriate conceptualization of SM has been highly debated over the years, and it was only very recently that the condition became classified as an anxiety disorder (Bogels et al., 2010). Many earlier accounts conceptualized the child’s failure to speak as an inability to speak (e.g., a language development problem). Due to its unique and rare presentation, and the long history of misunderstanding of SM, many affected youth have historically been misdiagnosed as having a language disorder, developmental delay, intellectual disability, and/or autism spectrum disorder. Other earlier accounts placed emphasis on the child’s voluntary, or “elective,” refusal to speak, which focused attention on oppositional and noncompliant aspects of the condition rather than on the anxiety-reducing functions of the condition. As research in recent years has more squarely clarified that anxiety and associated avoidance is at the center of SM, it has become increasingly clear that exposure therapy should be at the center of its treatment (Bergman, Gonzalez, Piacentini, & Keller, 2013; Cohan, Chavira, & Stein, 2006; Muris & Ollendick, 2015). Bergman et al. (2013) conducted the first controlled trial of SM treatment, and found strong support for a 6-month, weekly behavioral treatment that centered on graduated exposure to verbal communication. In fact, 75% of treated children were deemed treatment responders by independent evaluators masked to

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treatment condition. Since this initial trial, a growing body of literature has provided continued conceptual and empirical support for the use of exposure therapy to treat SM in childhood (e.g., Oerbeck, Overgaard, Stein, Pripp, & Kristensen, 2018; Oerbeck, Stein, Pripp, & Kristensen, 2015). Most recently, in a waitlist-controlled trial, Cornacchio, Furr, Sanchez, et al. (2019) found that up to 50% of children with SM were classified by independent evaluators as clinical responders after participating in a 1-week intensive group behavior treatment (IGBT) program that centered around graduated exposure to verbal communication. Treatment gains associated with this exposure-based summer IGBT endured into the following school year, during which time treated children showed significant improvements in SM severity, global functioning, overall anxiety, and verbal behavior in the home, school, and peer settings. Treated children also showed significantly reduced academic impairments in the year following this exposure-based summer IGBT. In light of growing consensus regarding the critical role of exposure therapy in the treatment of childhood SM, the present chapter offers a guiding overview of the core principles, practices, and procedures for implementing effective exposure therapy for SM. The key elements of exposure-based treatment for SM—including proper assessment, psychoeducation, reinforcement, stimulus fading, shaping, coping strategies, development of a fear hierarchy, graduated exposures, reinforcement, and homework—are each discussed in turn, as well as issues related to promoting generalization of skills in the community, collaborating with schools, calibrating for comorbidity, improving treatment access, and considering multimodal treatments that incorporate psychotropic medication. But first, we turn our attention to important developmental and clinical considerations.

Exposure therapy for selective mutism: developmental and clinical considerations Although SM is now classified as an anxiety disorder and most modern conceptualizations of SM focus on the anxiety-reducing function of verbal avoidance, it has become increasingly clear that traditional CBT methods for treating the common anxiety disorders are limited in the extent to which they can adequately address the unique clinical and developmental challenges associated with SM. Given the earlier onset of SM relative to other anxiety disorders, children being treated for SM commonly lack many of the developmental capacities required to effectively participate in thought monitoring activities, cognitive restructuring, mood identification, and perspective taking exercises (Carpenter, Puliafico, Kurtz, Pincus, & Comer, 2014). Accordingly, effective

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exposure therapy for SM—particularly for early child SM—often places greater emphasis on the behavioral, rather than cognitive, aspects of treatment. Behavioral strategies for treating childhood SM focus largely on reshaping the context of expected child verbal behavior and adjusting contingencies in children’s social worlds associated with verbal and nonverbal child behavior. On a related note, the limited executive functioning, restricted attention, and poor organizational skills that characterize early childhood cognitive development often compromise the extent to which young children with SM can be effectively treated with individual therapy or can be assigned homework exercises to be completed independently. For all of these reasons, family-based approaches—or at least treatments that include a significant parent component—are almost always preferred in the treatment of childhood SM. Moreover, the unique symptoms of SM (e.g., failure to speak with unfamiliar adults, limited verbal responses to questions) are often treatment interfering behaviors, limiting the extent to which therapists are able to directly engage children in the traditional interactive communication, reciprocal discussion, and Socratic dialogs that are central to supported CBT for the more common child anxiety disorders. Therapists with minimal experience working with children with SM will commonly find themselves either: (1) asking the child lots of questions and awkwardly getting no responses as they try to address their intended treatment material or (2) finding themselves covering all of their intended treatment material in a unidirectional monologue/presentation manner with little or no engagement or interactivity with the child. Both of these therapeutic patterns can inadvertently accommodate and exacerbate the child’s verbal avoidance, fail to meaningfully engage the child in treatment, discourage or rupture therapeutic alliance, leave the therapist feeling ineffective, and most importantly result in limited SM improvement. Regrettably, when SM symptoms interfere with a therapist’s ability to engage a young child in the cognitive domains of care, some therapists with limited SM experience choose not to attempt the critical behavioral aspects of exposure therapy. Given the need to emphasize behavioral aspects of treatment when working with a young child with SM, the need to heavily involve the family, the need to adjust the contingencies associated with verbal and nonverbal behavior in the child’s social worlds, and the need to reshape the contexts and social interactions in which child speech is expected, an increasing number of clinical groups are modifying Parent Child Interaction Therapy (PCIT; Eyberg & Funderburk, 2011) to more effectively treat early childhood SM (Carpenter et al., 2014). PCIT—originally developed to treat early child externalizing problems—works by reshaping adult child interaction patterns and social reinforcers associated with the maintenance of child symptoms, and does so in a

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developmentally sensitive manner that does not directly engage young children in therapeutic tasks that may be beyond their cognitive developmental capacities. A growing body of research is increasingly supporting the strategic modification and augmentation of PCIT methods for the delivery of exposure therapy for early child anxiety disorders (e.g., Carpenter et al., 2014; Comer et al., 2012). Importantly, the PCIT format and its emphasis on the social contexts of child development do not immediately require verbal behavior from the child in order for the child to fully engage in treatment. This is critical because in order to establish an effective therapeutic alliance when treating a child with SM, treatment should not immediately require any verbal behavior from the child. PCIT adapted for SM (PCIT-SM; Carpenter et al., 2014) utilizes principles and specific core treatment strategies from the initial treatment stage of PCIT (Eyberg & Funderburk, 2011) to strengthen parent child (and therapist child and/or teacher child) relationships, prior to advancing to a subsequent stage of treatment that focuses on challenging the child to engage in anxiety-provoking activities, such as speaking to new people. Given the increasing role of adapted PCIT for the treatment of SM across a growing number of SM specialty clinics—particularly for the treatment of early child SM—we incorporate key components of PCITSM throughout our discussions below as we review the key elements of exposure-based treatment for SM: assessment, psychoeducation, reinforcement, stimulus fading, shaping, coping strategies, development of a fear hierarchy, graduated exposures, reinforcement, and homework.

Key elements of exposure therapy for childhood selective mutism Assessment Accurate assessment drawing on reliable and valid methods is the necessary first step in effective intervention. Given the behavioral scope of the symptoms at the core of SM, as well as variations in verbal and nonverbal behavior across different settings, a thorough, multi-method, multi-informant assessment is warranted. Such an assessment strategy entails a diagnostic interview and reports from multiple adults in the child’s life (e.g., parents, teachers), as well as structured behavioral observations (ideally across multiple settings and contexts). In addition to baseline assessment, questionnaires and behavioral observations should be administered at regular intervals throughout treatment in order to systematically monitor outcome and inform a responsive datadriven treatment approach.

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Across available diagnostic interviews, the Anxiety Disorders Interview Schedule for Children (ADIS-C, Silverman& Barlow, 1996) offers the most well-supported and comprehensive option. When working with a child with SM, typically only the parent interview is conducted, as SM symptoms will likely compromise a child’s engagement in a diagnostic interview. Not only will a diagnostic interview with a nonverbal child with SM likely yield only limited information, but spending a first encounter with a child with SM attempting to interview him or her for an extended period of time can easily backfire, making it even less likely the child will come to verbally respond to the therapist with time in treatment. Behavioral observation tasks for SM are varied and have received less empirical attention, but are extremely valuable in understanding the child’s presentation (Cornacchio et al., in preparation). These tasks often inform children’s communication with their parents (the only verbalization that may be present at the start of treatment), as well as with unfamiliar adults, and give the therapist a sense of how the child uses nonverbal behavior to communicate. One such observation task is the Selective Mutism Interaction Coding System and associated adaptations (SMICS; Kurtz, Comer, & Masty, 2007; Masty, Kurtz, Tryon, & Gallagher, 2009), during which the child is prompted to answer certain types of questions posed by their parent during parent child play. Codings are tallied during structured segments when the parent and child are playing in the room alone, as well as when a stranger is present. During the SMICS, the stranger eventually also asks the child a selected question, and child verbal and nonverbal behaviors are coded. To assess child verbal behavior in peer or classroom settings, the Verbal Output during Interactions in the Classroom Environment Coding System (VOICE; Hong, Cornacchio, Furr, & Comer, 2018), can be used. The VOICE has each child in a classroom setting asked a set number of questions in front of the other children during one part of the day, and a set number of questions with a new adult in a one-on-one context at another time in the day. VOICE coders tally how many questions the child answers in the peer group setting and in the one-on-one setting with the unfamiliar adult, the amount of prompts needed to elicit speech, and counts of spontaneous child speech. Both the SMICS and the VOICE have received preliminary empirical support in the assessment of SM, and have shown sensitivity to treatment-related change (Hong et al., 2018; Cornacchio, Furr, Sanchez, et al., 2019). Leading parent and teacher reports of SM and verbal behavior in community and school settings include the Selective Mutism Questionnaire (SMQ; Bergman et al., 2002), which assesses communication across community, school, and family settings, and the School Speech Questionnaire (SSQ; Bergman et al., 2002), which is completed

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by the teacher, reflecting school-based communication. Viana et al. (2009) offer a more comprehensive review of assessment options for childhood SM.

Psychoeducation and real-time parent coaching At the outset of treatment, psychoeducation about SM and its treatment is critical. Psychoeducation can serve to empower parents to become critical agents of change in their child’s treatment. When working in the context of a PCIT-SM approach, this is sometimes called the “SM Teach” session, and only parents attend. This session includes psychoeducation about the nature of child anxiety and its development and maintenance, and helps to normalize the child’s symptoms and put them into context. The therapist should discuss how fear is natural, normal, and harmless (e.g., Fear is designed to draw our attention to an immediate threat and keep us safe by activating our fight-or-flight system), but our anxiety systems can sometimes be oversensitive and perceive not-sodangerous situations to be scarier than they are. The “overly sensitive smoke alarm” analogy can help illustrate the point: A smoke alarm always goes off if there is smoke from a fire, but it also sometimes goes off when we overcook and burn food in the kitchen. The anxiety system is like a smoke alarm—it goes off when there is real danger, but as is the case with the overreactive smoke alarm it may also go off when there’s not necessarily any real danger. We don’t want to turn off the “anxiety alarm” entirely; we just want to increase its threshold for going off. The therapist should also discuss with parents how anxiety and inhibited speech is rarely the result of a single cause, but rather often the product of both hereditary and environmental factors. The therapist should then review common cycles of negative reinforcement associated with SM: Child is prompted to talk or engage in conversation - Child and adult anxiety increase - Child avoids (i.e., does not give verbal response) - Adult rescues (e.g., adult answers for child, or lets child respond nonverbally) - Child and adult anxiety lowered - Anxiety reduction is relieving and avoidance is negatively reinforced - Child is now less likely to verbalize in similar situations in the future. It should be emphasized that each time this cycle repeats itself, the child is further reinforced to avoid (i.e., not speak), rather than approach (i.e., speak) in situations in which their anxiety is heightened. Despite the short-term gain for both the child and the parent of reducing momentary distress, this cycle of negative reinforcement serves to entrench and maintain SM and avoidance behaviors in the long term. It is important to emphasize that anxiety is not the “fault” of the child or the parent(s), but that how parents respond in situations in

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which child speech is expected can either encourage or discourage the likelihood of their child responding verbally in the future. Patterns that can maintain and/or exacerbate child anxiety and SM in the long term include accommodating the child’s anxiety by allowing him or her to avoid feared situations, paying extra attention to anxious/avoidant child behavior, and/or being quick to comfort a child if he or she exhibits signs of anxiety. Although excessive comforting and reassuring can relieve a child’s anxiety in the moment, it also reinforces the display of anxious behavior. Additionally, parents may not know to praise “brave” (i.e., approach) behaviors. Adults often fail to notice when children face their fears (as such bravery is not as disruptive or salient as anxious and avoidant patterns), and therefore can miss key opportunities to acknowledge, praise, and reinforce brave child behavior. Therapists should emphasize to parents how reinforcing their simple attention can be. When working from a PCIT-SM framework, initial parental psychoeducation should also involve the teaching of Child-Directed Interaction (CDI) skills (see Table 6.1). CDI skills are the positive parenting skills that are taught and mastered in the first phase of treatment in traditional PCIT. Initially, CDI skills are introduced to parents to use during “special time” (i.e., 5 minutes of concentrated one-on-one play) with their child. The basic rule of CDI is to follow the child’s lead, while using specific positive attending skills to reinforce wanted behavior—in the case of SM, the wanted behavior is brave, approach-oriented behavior and verbal responding. While the therapist explains each CDI skill, it is important to elicit responses/feedback from the parent(s) about the definition, examples, and rationale for the CDI Skills. Further, the therapist should describe how each skill helps children “warm up” in new situations, without the expectation to speak, and guides parents to use positive attention alone to reinforce brave behavior. In addition to the CDI “Do” skills (i.e., labeled praise, reflection, and behavioral description), the therapist should also educate the parents about what not to do during special time. Parental “Don’t” behaviors (also taken from PCIT; Eyberg & Funderburk, 2011) that are important to avoid during CDI include Commands (in order to allow the child to lead the play and to reduce any negative interactions that may occur if the child does not comply), Criticism (negative evaluations of the child or his or her actions reduce the warmth of the interaction and corrective feedback takes away from the child’s lead of the play), and Questions (so that children do not feel pressure to speak). Avoiding parental questions in CDI reduces verbal expectations on the child during a time focused on letting the child lead the play, optimizes warmth and comfort in the parent child interaction, and often actually increases the likelihood that the child will respond once the therapist and/or parent

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TABLE 6.1 CDI skills (see PCIT Manual for thorough CDI description, Eyberg & Funderburk, 2011). Skill

Reasons

Examples

Labeled praise A positive statement about what the child is doing at the moment

• Increases the frequency of that specific behavior • Shows parents’ approve behavior • Improves confidence

Great job using your voice to answer my question! I love that you looked at me while you told me that.

Reflection A statement that repeats back to the child their verbalization or paraphrases what the child says Avoid “tip-ups” in tone of voice (i.e., reflections that can sound like questions)

• Shows others heard and understood verbalization • Improves child’s vocabulary • Increases verbalizations

Child: I’m hungry Parent: You said you’re hungry! Child: Where’s the bathroom? Parent: You want to know where the bathroom is.

Behavioral description A statement about the child’s moment-by-moment behavior Pretend you are a play-by-play sportscaster!

• Let’s the child choose what to do • Shows approval • Increases focus on activity • Models appropriate and may expand verbalizations and vocabulary

I see you shaking your head. You are coloring a flower with the red crayon. I see you smiling.

CDI, Child-Directed Interaction; PCIT, Parent Child Interaction Therapy.

begins to implement another set of skills that directly target child verbalizations. If the child misbehaves or displays inappropriate or avoidant behaviors during special time, parents are encouraged to use Active Ignoring of the behavior until the child engages in an appropriate or brave approach-oriented behavior. During CDI, a common PCIT rule of thumb is that if an unwanted behavior is not going to result in blood, bruises, or destruction of property, it is probably ignorable. In the context of SM, the unwanted behaviors are typically hiding, whining, clinging, behavioral inhibition, and other displays of shy, anxious, or withdrawn behavior. Therapists should reference the cycle of negative reinforcement and teach parents to remove their attention when their child is being avoidant (e.g. hiding, whining, clinging to parent), rather than providing comfort. Parents are taught that while ignoring, they should look for and positively reinforce (using CDI “Do” skills) any appropriate behavior(s) occurring at the same time (e.g., if the

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child is whining, but also coloring calmly). For example, the therapist may coach the parent to praise their child for engaging in play when a new person enters the room and ignore the child’s avoidant behavior of moving closer to her mother. Therapist: “Go ahead and scoot over a little so (child) is sitting on her own, now you can give her a praise for being brave and engaging in play on her own”; Parent: “I love that you are being brave by sitting on your own and coloring at the table while our new friend is in the room.” Parents are taught to focus on and give direct attention (via CDI “Do” skills) to the brave or appropriate behavior of which they want to see more (i.e., “positive opposites”), rather than attending to negative/undesired behaviors. For example, if a child typically avoids speaking aloud to her parent in public, the parent should praise the positive opposite, “I‘m glad that you’re using your big girl voice with me here in the store” or “I’m glad that you’re using some words here in the store that I can hear” (if the child is softly whispering). It is important to encourage parents to look for opportunities to praise the positive opposites of behaviors that they want to decrease (e.g., when a typically clingy child is sitting on his or her own). After the parents are able to master CDI skills, additional parental psychoeducation is incorporated in order to teach Verbal-Directed Interaction (VDI; see Carpenter et al., 2014). VDI skills are used to increase children’s speech by prompting for verbalizations from children in very specific ways (see Table 6.2) and following specific sequences (see Table 6.3) that optimizes the likelihood that a child will respond verbally. Therapists should emphasize that the contexts in which different types of questions and sequences are most appropriate vary based on numerous factors, some of which are outlined in Table 6.2. Parents are taught that the VDI sequence begins with a preferred question (e.g., an open-ended or forced-choice question, instead of a yes or no question). Once a question is asked, the adult should wait 5 10 seconds for the child to answer. This allows the child ample time to respond, without giving them an easy opportunity to quickly avoid. When asking a question of a child with SM, we commonly see parents and other adults rush in too soon and repeat their question, answer the question for the child, or very quickly move on to something else before the child has even had a true opportunity to answer. We find this is often the result of the adult prematurely assuming the child will not answer this question (based on their previous experiences with the child) or the adult’s discomfort with enduring an awkward silence associated with giving the child some extra time to respond. Either way, failing to give a child with SM adequate time to respond can communicate a number of unwanted messages to the child (e.g., the

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TABLE 6.2

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Some important Verbal-Directed Interaction (VDI) question types.

Type of question

When to use

Examples

Forced choice A question in which two or more possible responses are given within the question

• Good when starting out • They provide the child with the answer within the question, making it easier for the child to respond

• Would you rather play on the swings, the slide, or you don’t know? • Do you want to see the movie Frozen or another movie?

Open-ended A question in which a possible answer is not suggested within the question. E.g., who, what, when, where, why, or how

• Provide the child the opportunity to express their thoughts more than other types of questions • Allow the child to produce a response on their own

• Who is your best friend? • What did you learn today at school? • Where did you go over the winter break?

Yes or no A question in which a possible or expected response is either “yes” or “no”

• These questions should be avoided, as they can be answered fully in a nonverbal manner (e.g., head nod) • A simple way to change a question from a yes or no question to a forced-choice question is by including yes or no within the question

• Do you like seafood? • Instead: Do you like seafood, yes or no? • Did you do your homework? • Instead: Did you do your homework or not?

VDI, Verbal-Directed Interaction.

adult does not have confidence in my ability to speak; the adult is uncomfortable with me; I don’t need to respond the first time an adult asks me to say something because they’ll just keep asking). Therapists should teach parents that if the child does answer, the therapist or parent should immediately respond with a labeled praise (e.g., “Thank you for answering my question” or “Great using your brave voice”). If, on the other hand, the child does not answer within 10 seconds, the adult repeats the question, or asks an “easier” question (e.g., instead of repeating an open-ended question, rephrasing the question as a forced-choice question). Again, if the child answers, the adult should immediately give a labeled praise for his or her “brave talking.” If the child responds nonverbally, the nonverbal behavior is described, but the message the child is intended to communicate nonverbally is not accepted as a response and the child is re-prompted to respond verbally (e.g., “I see you are pointing, do you want to play with the blocks or the trains?” or “I see you are nodding your head, do you want to

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TABLE 6.3 Example VDI sequences. Immediate response Adult: “Would you like to use crayons or markers to draw?” (forced choice) Wait! 1 2 3 4 5 seconds Child: “Markers.” Adult: “Markers!” (reflection) “Great job telling me what you wanted to use!” (labeled praise)

Difficulty choosing Adult: “Do you want chocolate or vanilla ice cream?” (forced choice) Wait! 1 2 3 4 5 seconds Child: No response. Adult: “Chocolate or vanilla?” (forced-choice) Wait! 1 2 3 4 5 seconds Child: No response. Adult: “Do you want chocolate, yes or no?” (forced choice) Child: Nods head. Adult: “I see you nodding. Is that a yes or a no?” (forced choice) Child: “. . .yes” Adult: “Yes, you want chocolate.” (reflection) “Good job telling me what you want!” (labeled praise)

Nonverbal response Adult: “Would you like to use crayons or markers to draw?” (forced choice) Child: Immediately points to markers. Adult: “I see you pointing.” (description) “Does that mean you want the markers or crayons?” (forced-choice) Wait! 1 2 3 4 5 seconds Child: “I want the markers.” Adult: “You want the markers!” (reflection) “Super job telling me what you wanted using your words!” (labeled praise)

Barely audible response Adult: “Do you want to watch Cinderella or Frozen?” (forced choice) Wait! 1 2 3 4 5 seconds Child: Under breath “F.o.z.n.” Adult: “I hear you trying to answer.” (describing) “I couldn’t hear you. Say it again a little louder.” (direct command) Wait! 1 2 3 4 5 seconds Child: “Frozen!” Adult: “You want to watch Frozen!” (reflection) I love that you told me that with a loud voice!” (labeled praise)

Whisper response Adult: “Do you want to eat your sandwich or your pretzels first?” (forced choice) Wait! 1 2 3 4 5 seconds Child: Whispers “sandwich.” Adult: “I hear you whispering.” (description) “Tell me what you want with your full voice” (direct command) Wait! 1 2 3 4 5 seconds Child: “Sandwich” (full voice) Adult: “You want to eat your sandwich first!” (reflection) “Great Job using your full voice to tell me!” (labeled praise)

No response Adult: “Would you like cookies or crackers as a snack?” (forced choice) Wait! 1 2 3 4 5 seconds Child: No response Adult: “Crackers or cookies?” (forced choice) Wait! 1 2 3 4 5 seconds Child: No Response Adult: “Do you want cookies for snack, yes or no?” (forced choice) Child: No response Adult: “It might be hard to answer in front of all of these people, let’s go practice in the hallway.” OR “That might be hard to answer right now, think about it and I will come back and ask you in a little bit.” OR “Go practice with mom and then come back and tell me.”

VDI, Verbal-Directed Interaction.

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play with the car, yes or no?”). We advise parents that a question may be repeated up to three times. This VDI sequence teaches children that the expectation is always a verbal response. However, if the child does not verbally respond after three prompts, the following additional strategies can be recruited: (1) shaping, which will be discussed below (e.g., first answering a stranger’s question to a parent and gradually shifting to responding directly to the stranger), (2) practicing in an easier setting (e.g., the child may need to be taken to a more comfortable space to practice responding to the question, before returning to and successfully responding in the original context), (3) returning to the last situation where the child was verbal (e.g., may return to outside of the school if child stops speaking in classroom, hallway, etc.), or (4) postponing (e.g., recognizing the question may have been too difficult for the moment, but planning to revisit the question to ensure success at a later time; e.g., “That might be hard to answer right now; I’ll come back and ask you in a few minutes”). The goal of these strategies is to promote child success, even if the task is broken down into smaller steps. Table 6.3 presents some sample VDI sequences. When the VDI sequences are used consistently, the cycle of negative reinforcement is broken and the child learns a new strategy for reducing their anxiety: speaking. Although psychoeducation about CDI and VDI sequences is important, psychoeducation alone is not sufficient. Most parents will understand and agree with the strategies taught, but true learning that leads to downstream change in child verbal behavior typically only happens through direct therapist coaching of parent child interactions. Effective PCIT-SM approaches follow psychoeducation with extended sessions that draw on unobtrusive, real-time, bug-in-the-ear parent-coaching strategies (e.g., via walkie-talkie or Bluetooth earpiece communication through a one-way mirror) to help parents practice and master CDI and VDI sequences with their child in increasingly difficult situations.

Reinforcement Reinforcements are consequences of certain behaviors that make it more likely that those behaviors will occur again in the future. A primary goal of the CDI and the VDI sequences are to provide social reinforcement and differential social contingencies for brave and verbal behavior. For most children, labeled praise and parental attention for child verbal behavior increase the likelihood of continued verbal responding from the child. And conversely, removal of parental attention (e.g., active ignoring of child whining and nonverbal responding) typically decreases the likelihood of continued nonverbal responding.

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In addition to emphasizing social reinforcements, parents should be guided through the use of tangible positive reinforcement systems through which their child will have the opportunity to earn a small reward for exhibiting appropriate behavior and meeting specific goals during each treatment session (e.g., brave talking, playing nicely with toys). Goals may include answering a parent in the room alone, answering a parent with a therapist present, answering a parent with the therapist next to the child, answering the therapist directly, and so on. One example of such a reinforcement/reward system begins with the use of a “brave chart.” In this system, the child earns checks on a chart each time he or she meets a goal to encourage and validate positive behaviors (e.g., brave talking). The therapist should orient the child without expecting any verbalizations, “I love how you are playing with your Mom so nicely. You will get to earn lots of checks today for using your brave voice with new people today! Once you earn 10 checks you will get a gold coin, and you will get to take all of the gold coins you earn to the treasure chest at the end of the day. I bet you will be so brave and earn lots of gold coins.” Each time the child is successful in meeting a goal, a check is placed in one of the blanks on the chart (e.g., in one of ten squares). When the chart is completed (e.g., all 10 squares are filled), the child receives a coin, and at the end of session, the child can “cash in” coins for a prize from a “treasure box” (or another reward upon which the child and parent or therapist have agreed). Other examples of tangible reward systems include using stickers, small candies, points, or some other type of interim reward to hold the place for larger prizes the child can earn at the end of each session or several sessions.

Stimulus fading Stimulus fading is a behavioral procedure that entails the gradual approach of the feared stimuli (e.g., an unfamiliar person) closer to the child, allowing time for habituation (or adjustment) to the stimulus prior to each move closer. Stimulus fading is commonly used in treatment for anxiety and SM specifically (Viana et al., 2009). “Fade-in” strategies can be used in any feared situation and encourages the child to approach, rather than avoid these situations. For children with SM, exposure practice fade-in refers to gradually introducing a new individual (i.e., a person the child has not verbalized to or in front of before) into the child’s speaking circle. Typically, the new individual gradually gets closer in proximity to the child, as the child continues to speak to someone already in their speaking circle. Eventually, the new individual becomes engaged in the activity and additional strategies are used to promote the child’s ability to speak to the new individual.

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An initial fade-in session in PCIT-SM typically begins with the child and parent together in a room alone. To help the child warm up and feel more comfortable, the parent is coached to engage their child in CDI. Once the child is engaging with the parent, the parent is coached (via an unobtrusive bug-in-the-ear approach) through VDI sequences, in order to promote child speech and verbalization while it is just the parent and child in the room. Once the child is responding consistently to the parent, the fade-in of a new person begins. It is often beneficial to have two therapists present for this initial session—one to coach the parent and one to fade-in with the child, while using CDI and VDI skills. Alternatively, it is recommended that the therapist have the ability to coach both parties (i.e., the parent, and the new person who may not have any formal training) through use of two walkie-talkie sets or other bug-in-the-ear technologies. The unfamiliar person (e.g., the second therapist) may begin by sitting outside of the therapy room with the door slightly open until the child maintains or resumes verbal communication with his or her parent. The unfamiliar person might slowly open and/or move slowly into the entrance of the room, careful to move closer only as the child remains consistently responsive to the parent. For example, if the child reduces his or her speaking behavior, the unfamiliar person must wait to move closer until the child again continues to speak with the parent. The unfamiliar person is coached to begin using CDI skills once they are in the clinic room with the child (e.g., reflection: “You told your mom you wanted to play with the dolls”; labeled praise: “You are being so brave and talking to mom loud enough for me to hear” or “You’re playing so nicely in here”; behavior description: “You are driving the car along the track”). Once the child is speaking comfortably in front of the unfamiliar person, that person can begin prompting the child using VDI skills. The quickness with which successful fade-ins occur will vary across children. At first, the child may only answer the unfamiliar person’s questions to their parent(s) or in a barely audible volume. Shaping techniques (discussed subsequently) may be necessary in order to support the child in speaking directly to the unfamiliar person. Once the child is speaking to the unfamiliar person, the parent is coached to slowly move out (i.e., “fade out”) of the room while the child engages with the unfamiliar person, typically at a rate similar to the speed with which the fadein process took. One goal of the first fade-in session is for the child to speak with the unfamiliar person with the parent outside of the room. However, this first step may take more than one fade-in session. Importantly, throughout the session, the child is continuously rewarded through checks (i.e., immediate reinforcement) for speaking. Fade-ins can be used in clinic settings, as well as in home and community (e.g., school) settings, to introduce new people into the child’s speaking circle.

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Shaping Shaping consists of rewarding successive approximations of desired behaviors. Children with SM, in particular, often require smaller steps to reach an ultimately desired outcome. For example, when a new person asks a question, it is wise to reinforce the child for a response directed to the parent, rather than to the new person, as this represents a step toward the child answering directly to the new person (e.g., parent: “Thank you for answering a new person’s question!”). Shaping may also include having the parent move closer and closer to the new person as the child continues to direct answers to the parent, until the child is able to transfer the verbalization to the new person (e.g., first looking at the new person’s shoulder when responding, prior to making eye contact with the new person while speaking; parent: “Thank you for answering their question to me, now tell my shoulder. Great telling my shoulder, now tell her shoulder. Awesome telling her shoulder! Now look at her and tell her. Amazing job looking right at your new friend and telling her your favorite color!”). Another example of shaping includes having the parent start a question or response, but the child finishing it like a fill-in-the-blank (e.g., parent: “what’s your. . .”; child: “name?”). Many aspects of the child’s behavior can be shaped, including to whom the child is speaking, volume, eye contact, and distance from the desired target person. It is important to reward the child for each successive approximation with positive attention and/or concrete reinforcement (e.g., checks on the brave chart, stickers, treats).

Coping strategies For older children and those having difficulty participating in fadeins and shaping activities, coping strategies may help the child manage interfering emotions and/or cognitions. Coping strategies include, but are not limited to, progressive muscle relaxation, deep breathing, distraction, mindfulness, and coping thoughts (e.g., I have done this before, I can do it again; It will be worth it). Muscle tension and progressive muscle relaxation exercises can be used to help children notice how their bodies tense when they are anxious and help them learn how to relax their muscles. In the “squeezing lemons” activity, the child is told to pretend they have lemons in their hands and is instructed to try to squeeze out all of the lemon’s juice, before letting go. This activity helps the child learn how to tense and relax their muscles. Deep breathing can be taught in a child-friendly manner through “pizza breaths.” The therapist should explain this exercise in a fun and engaging manner and have the child practice with them (e.g., Now pretend you are holding a fresh hot slice of (child’s favorite type) pizza. You are really

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hungry and want to take a bite but the pizza is too hot. First, take a long, deep breath in through your nose to smell the delicious pizza. Then, let the air out slowly through your mouth to cool off the pizza. Let’s try it again!” This activity is used to teach children how to use slow, diaphragmatic breathing to calm their heart rates and relax their bodies. Distraction techniques can also help to get the child to engage in exposure tasks. Although we want children to learn to face their fears and engage in exposures, rather than avoid them, it is occasionally difficult to get children to move toward fearful situations (e.g., new people). At times, distracting the child with an activity or game that they find enjoyable can change their cognitive or emotional state and help them to approach the situation rather than avoid it. For example, playing a really fun, interactive, and/or physically engaged game, can occasionally reduce anxiety or increase motivation because the child is so immersed in the game that they are more easily able to engage in the exposure task or can at least move closer to the goal. Younger children who may not have the developmental capacity for reflecting on their anxious cognitions and modifying them may also benefit from simple coping thoughts to boost themselves up before engaging in an exposure task (e.g., I can do it; I can be brave).

Fear hierarchies and graduated exposure activities Prior to initiating full-scale exposure activities, it is important to recognize the spectrum of the child’s fears. This includes not only identifying situations that elicit fear, but also documenting to what extent each situation provokes anxiety and associated avoidance. Clinicians typically utilize a scale or fear thermometer that ranges from 0 (no fear or avoidance present) to 10 (extreme fear or avoidance present). This activity is often referred to as building a “fear hierarchy” (or “fear ladder”) because ultimately, these situations are listed in order of difficulty and serve as a roadmap of exposures to progressively climb. In the event that multiple situations are considered equally anxiety provoking, other factors are drawn upon to determine the order in which they should be listed (e.g., the frequency with which the child typically encounters the situation, the extent to which the family wants to prioritize various situations). An example of fear hierarchy is presented in Fig. 6.1. Importantly, while this example uses “speaking” as the target behavior, children with SM present with many variations in the nuances of what makes speaking difficult (e.g., responding vs initiating, whispering vs audible speech). Clinicians and families are expected to work together to identify the extent to which these nuances should be captured on the fear hierarchy and corresponding exposure tasks.

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Situation Speaking to teachers at school during a group lesson

Fear rating (0–10) 10

Avoidance rating (0–10) 10

Speaking to teachers alone at school

10

10

Speaking to peers alone at school

10

10

Speaking to parent(s) at school with teachers present

9

9

Speaking to parent(s) at school with peers present

9

8

Speaking to parent(s) at school without others present

8

6

Speaking to parent(s) at home with unfamiliar adults present

8

6

Speaking to parent(s) at home with familiar adults present

7

4

Speaking to peer(s) alone at home

6

3

Speaking to parent(s) at home with unfamiliar children present

5

3

Speaking to parent(s) at home with familiar peers present

3

3

Speaking to parent(s) in the home without others present

0

0

FIGURE 6.1 Example of fear hierarchy.

Furthermore, fear associated with speaking may vary by context (e.g., location, age or familiarity of people involved). For example, in the fear hierarchy illustrated in Fig. 6.1, the child is least anxious (i.e., fear rating of a 0 out of 10) speaking to parent(s) at home without anyone else present. As the fear hierarchy becomes increasingly challenging (e.g., fear ratings of 6 10 out of 10), it is apparent that the child is less comfortable with older, unfamiliar people, in the school setting, than (s) he is with younger, familiar people, in the home setting. These details become important in subsequently deciding the most appropriate approach toward designing corresponding exposure tasks for the items on the fear hierarchy. Corresponding exposure tasks are designed in collaboration with the family once the fear hierarchy is established. Of note, each situation listed on the fear hierarchy may be targeted through multiple, increasingly challenging exposure tasks. There can often be quite a bit of overlap between the exposure tasks that are designed for each item, as the principles of stimulus fading and/or shaping are frequently utilized to ensure the child’s success in completing each exposure task, prior to moving on to the next one (e.g., new individual moves closer, familiar individuals move further away, louder volume is prompted). Examples of corresponding exposure tasks associated with the least anxiety-provoking situation from the example fear hierarchy are presented in Fig. 6.2. Additionally, examples of increasingly challenging exposure tasks related to speaking in the community are presented in Fig. 6.3.

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Exposure 1: Speak to the parent in a room with the door closed, while a familiar child is outside of the room Exposure 2: Speak to the parent in a room with the door open, while a familiar child is outside of the room Exposure 3: Speak to the parent while a familiar child sits on the opposite side of the room Exposure 4: Speak to the parent while a familiar child is sitting next to the child

FIGURE 6.2 Sample exposure tasks corresponding to the fear of speaking to parent(s) with familiar children present. Exposure 1: Respond to the parent asking questions about the order while on line Exposure 2: Respond to the parent asking questions about the order at the counter Exposure 3: Respond to the employee’s question about the order by directing the response to the parent Exposure 4: Respond directly to the employee’s questions about the order

FIGURE 6.3 Sample exposure tasks corresponding to the fear of ordering ice cream at a counter.

These examples highlight the graduated approach of exposure therapy applied to reduce symptoms of anxiety related to speaking under various conditions. However, it is important to distinguish “graduated” from “slow.” Oftentimes, when describing this systematic approach, therapists use an analogy of climbing a ladder. Children may climb ladders at various speeds—it may be that one child begins climbing the ladder very quickly, but after taking a few steps, needs to slow down. Alternatively, another child may begin climbing the ladder very slowly but after taking a few steps is able to speed up. The speed with which the child climbs the ladder may vary, but one thing should remain consistent: the child should place his or her foot on every step without skipping any, to ensure they do not “fall off of the ladder” as they are climbing. This analogy relates to exposures in that some children will be able to move through their hierarchy quickly, while others may take more time. Regardless of the speed with which a child is able to graduate to increasingly difficult exposure tasks, it is important to remain systematic in the approach: if a child is prompted to skip steps of his or her ladder, it can result in the child shutting down in response to an exposure task that was too challenging to ensure their success. In the context of SM treatment, moving too soon to the top of a fear ladder, and associated setbacks, can have a particularly deleterious effect on child motivation. In general, utilizing a systematic approach increases the likelihood that children are successful in participating in exposure tasks. However, there are still occasions in which children unexpectedly shut down

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when prompted to complete an exposure task (sometimes even when they have been successful completing the very same task in the past). When this occurs, the clinician is encouraged to evaluate the factors may have resulted in this difficulty, while reengaging the child. This reengagement often includes a return to the last context in which the child was successful. For example, if the child was previously able to answer the clinician’s questions in front of a novel individual, but was then unable to answer directly to that novel individual, the clinician may return to being the one to ask the question. The clinician may do well to utilize CDI skills to reinforce the child’s speech, before returning to the originally intended exposure task with additional supports (e.g., increased shaping practices to facilitate success). In general, when a child is unsuccessful in responding to an exposure task, returning to CDI, setting up additional practices to prepare for the next attempt at the exposure, and increasing support during the next attempt will optimize the likelihood of success in subsequent attempts.

Homework and promoting generalization in the community In sessions, skills are taught, parents are coached in the parenting practices that optimize brave verbal talking, and children practice exposures. But meaningful change in child verbal behavior is rarely achievable in the absence of systematic out-of-session practice. In PCIT-SM approaches, in the earlier phases of treatment, parents are assigned to practice using CDI skills with their child during 5 minutes of “special time” each day in order to afford parents the opportunity to practice and provide the child with a therapeutic dose of positive attention each day. Later in treatment, parents are assigned to continue incorporating five minutes of CDI “special time” into each day, but to additionally begin to practice VDI skills and sequences on a daily basis. Once a child begins to make progress in the clinic setting and skills are being mastered at home, it is important to focus the family’s efforts on the variety of community settings in which the child engages. Fear hierarchies specific to various community settings can be made in collaboration with the child to identify the situations to best target and to determine the order they should be engaged. What to say when someone asks why a child does not speak In the community, parents of children with SM may get asked about why their child is not talking or if something is wrong. Others are looked at as if their child is being rude or disrespectful. It is helpful for the therapist to understand parents’ perspectives and emotional responses to such questions and reactions from people in the

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community (e.g., embarrassment, disappointment, frustration, sadness, anger), and to explore with them how their responses can have positive or negative effects on the likelihood their child will speak in public in the future. The therapist should normalize parents’ reactions and validate how challenging these situations can be, as well as any potential feelings of defeat, guilt, or embarrassment. Parents often report they feel obligated to explain the “entire situation” of SM (e.g., the diagnosis, the myth being “just shy,” that their child is not just being rude) when they are asked why their child does not speak. This can become discouraging to parents. Parents with anxiety themselves, may come to increasingly avoid public settings with their child just to avoid these conversations. Such parental avoidance is particularly interfering when treatment assigns homework for the family to practice in the community, and so it is helpful to give parents quick tools to help navigate these uncomfortable situations. Parents can be encouraged to use a brief statement about how their child is working on brave talking, being brave, or practicing talking, and that others’ help is much appreciated. Having lengthier discussions about the “entire situation” of SM in front of the child can shame or embarrass the child and make it less likely for the child to respond. SM may affect a child’s verbal behavior, but it does not affect a child’s ability to listen or pay attention. If it feels appropriate to share a child’s full history of SM and/or other details (e.g., perhaps with a close relative), it is recommended that parents do so at a time when the child is not present. Question cards and generalization practices Many families report that the hardest part of generalization practice is that they are uncertain about what others will ask their child and that their child may be unprepared to answer in the moment. One easy way to help the child be successful during generalization practice is to have the parent and child generate several “go-to” questions that the child has practiced many times and feels comfortable answering and asking. These questions can be written on cards that can be used to direct conversations and exposure practices in public settings. Such question cards can really help set a child up for success in answering questions during generalization practice. For example, when someone approaches a child and asks a random question or questions (e.g., “Hi! How are you? What have you been up to?”), it may be especially challenging for a child with SM to answer. However, the therapist can prepare parents for these situations with the following: • Parents can say, “Thanks for asking her that question. She is practicing her brave talking—would you mind asking her one of the

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questions on this card instead? We would really appreciate your help.” What happens if they don’t respond? Therapists should encourage parents to expect this may happen, but to model brave behavior and appropriate coping modeling. “This is likely, especially in the beginning of treatment. Stay calm. Don’t panic. Remember, your child will pick up on your cues of being nervous or worried that they are not going to perform as expected.” If a person asks the child a question, and the parent has waited 5 10 seconds, parents are encouraged to prompt the person to ask the question again (“Do you mind asking him that question again?”), to prompt the person to give the child choices (“Could you give him some choices?”), or to ask the person to ask a different question (“Do you mind asking him about his favorite color? He is really good at answering that question”). If child is still unable to answer, discuss with parents how to have a brief practice in front of the other person, by having the child step closer to the parent and to simply turn away from the person asking the question towards the child. In the spirit of shaping, the parents can then have the child give an answer to the parent first, followed by a prompt for the child to tell the other person the same answer. If after these prior steps, the child is still unable to answer, the parents should feel encouraged to take the child out of the room or space in which the exposure is occurring and to practice with their child in another space how to answer the question. Parents can problem solve ways in which to make out-of-session practice easier, for example, taking some pizza breaths, or having the parent start to answer, and the child finishing it (Parent starts “My favorite color is. . .” Child finishes with “blue.”). Then the parent would have the child respond with a full sentence on his or her own (“Okay, now tell him, “My favorite color is blue.” Child repeats). Each step of the process in which the child is able to perform, the parent should provide positive attention and reinforcement. Question cards can also be used to prompt the other person to praise your child after asking questions by ensuring that an example of a labeled praise is listed at the bottom of the card (e.g., “Thank you for letting me know what you like”). The card can also be used to prompt the child to ask questions of the other person.

The therapist should recommend that parents take the child’s brave chart with them to all outings and social environments in which brave talking is expected. Early on in treatment, the child will likely need more support in the form of immediate checks or stickers in their chart, and later in treatment the child may only need to use the chart in

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specific challenging situations. Moreover, prior to going to an event or into an exposure situation, the parents should discuss the goals and expectations for that situation with their child. For example, many parents automatically turn to their child and prompt them to say “hi,” but this specific practice should not be prompted unless it has been discussed ahead of time and the child is ready to work on that particular goal. It may also be easier for parents to initially facilitate their child answering a go-to question or a fact-based question (e.g., one listed on a question card) than to facilitate their child saying “hi” to a new person. The therapist should encourage the parents to make practice a part of daily life. All social situations have inherent opportunities for reinforcing brave talking. Thinking ahead about how to best set up exposures will support a child’s success (e.g., use of fear hierarchies and corresponding exposure tasks planned in advance). At times, public exposure practice may require therapist support. For therapists with limited opportunity to leave their office, this can easily be accomplished through the use of videoconferencing on smartphones and the parents’ use of a Bluetooth earpiece for live coaching (Comer et al., 2015, 2017; Comer & Myers, 2016). Such modern telehealth technology allows the therapist access to practices in the home and in community settings that until recent years were out of reach for many therapists unable to leave the office setting for exposures. Generalization in schools One of the greatest challenges for children with SM is fostering or restoring verbalization in the school environment. Although many parents are hesitant to involve schools in their child’s mental health treatment, given that school settings are among the most problematic and impairing for children with SM, it is almost always imperative to engage the child’s school in treatment and for parents and therapists to provide the school with all of the same information and resources they have to support their child’s progress. The school setting is most likely an area of “contamination”—a place in which the child has a history of not speaking and is known as “a child who doesn’t talk.” However, by working collaboratively with school staff, change can happen. Either prior to the academic year or as soon as treatment begins, it is recommended that the therapist encourage the parents (or professional staff/ counselors) to provide psychoeducation to as many school staff members as possible. Often this training can be conducted during a professional development day, or at any other time that the school allows. The most important aspect is that the training includes the child’s main classroom teacher(s). For those operating from a PCIT-SM framework, this school training should cover VDI skills and sequences, with didactics, role-plays, and

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handouts. The fade-in process and shaping procedures should be reviewed in depth in order to help teachers develop plans for introducing peers and school staff into the child’s speaking circle. It is advised that the therapist travel to the child’s school (or collaborate via telehealth technology) in order to coach teachers through fade-in procedures to ensure that the child can speak with at least one person in the school setting. This person can help be the champion to furthering the child’s speech with other staff and students. Typically, before or after school (or during lunch) are good fade-in times. Such times may be easier for the child since at these times there are typically fewer or no children present in the school or classrooms. The starting point for the fade-in procedure will depend on the schoolrelated contexts in which the child is unable to speak. For example, most often, the fade-in can occur in the classroom; however, some children need to start on the playground, a hallway, or the parking lot, depending on the last place the child speaks before entering the school building or classroom. Parents can prepare their child for school fade-in procedure by reminding the child of the goals and associated rewards. Once at school, the fade-in should begin with CDI time in the specified location. Once the child is comfortable and consistently verbal, the target teacher or student should slowly begin to fade into the interaction, as the child continues playing with the parent or therapist. This fade-in should continue to follow the fade-in procedures previously described. During this initial fade-in, the therapist may encourage the teacher to ask typical questions related to class (e.g., the date, class job preference), so that the child has the opportunity to practice answering these questions prior to being prompted in the larger classroom setting. As in other fade-in sessions, the parent and/or therapist should fade out of the room to ensure that the child is able to continue speaking to the teacher alone. This same procedure can be used with anyone in the school setting. Once successful fade-ins have occurred with the teacher, it is important to establish a behavior chart or daily report card (DRC) that promotes clear communication between the home and the school. With this system, teachers can provide daily communication to the parents about the verbalization goals that have or have not been met on a daily basis. Some parents and teachers prefer to use the same brave chart system used in treatment, whereas other teachers prefer to incorporate this reward system into existing classroom reinforcement systems. The teacher should send home a report (e.g., DRC, brave chart) related to the child’s goals (i.e., one or two goals per day) on a daily basis, so that the child’s parent can review the child’s progress and provide rewards for meeting goals at home. Through this system,

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the teacher is relieved from the responsibility of providing rewards to the child in the classroom setting, though teachers can provide separate rewards at school if necessary and/or feasible. Relatedly, some children may require more frequent reinforcement in order to remain verbal and the level of reinforcement can be monitored and adjusted accordingly.

Challenging issues in exposure therapy for childhood selective mutism Education accommodations Many children with SM experience academic impairment, such as failing presentations, reading groups, or other educational tasks that involve speaking or participation. Therefore, parents of children with SM who are experiencing academic interference are encouraged to set up a 504 Plan or an Individualized Education Plan (IEP) to support their child’s needs and accommodations, as well as to ensure that these accommodations will be continued through the following academic year. An IEP is used if the child needs specialized instruction. For a child who does not need specialized instruction, the 504 Plan should be sufficient to provide necessary accommodations. The 504 Plan is a strategy developed to ensure that a child who has a disability identified under the law receives accommodations that will ensure their academic success and access to the learning environment. The 504 Plan describes the accommodations that the school will provide to support the student’s education. Examples of good accommodations to incorporate in a 504 Plan for a child with SM include the use of specific question types (e.g., forced-choice questions) or types of praises, instruction for teachers to wait 5 10 seconds for the child to respond after prompting, and/or small group time with preferred peers for reading groups or projects, all to promote greater verbalization in the classroom. Examples of misguided accommodations to incorporate in a 504 Plan for a child with SM include allowing the child to have a close friend speak/interpret for him or her, or allowing the child to write down answers instead of verbalizing responses to teacher questions. The process for instituting an IEP takes more time to implement than the 504 Plan, as an IEP requires academic testing, observation, and specific data to support the need for the IEP. Each state and school district may have different requirements, eligibility criteria, and procedures for these accommodations, so therapists should be prepared to flexibly support the family and school to best inform this process.

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Comorbidity As noted previously, comorbidity is the norm, not the exception, when it comes to children with SM. For many comorbidity patterns, it is critical to address the SM first, prior to focusing on other clinical targets. This is because SM symptoms themselves are often a treatment interfering behavior and can compromise child engagement in other therapeutic tasks. For example, it is very difficult for a therapist to have an interactive session focused on helping a child rethink his or her anxious thoughts, or focused on collaborative problem solving, if the child will not speak to them in session. Further, when a child’s comorbid case presentation includes a diagnosis of SM, the SM symptoms are often most impairing and warrant immediate attention—particularly when school participation and performance is affected. When sequencing treatment, often the most interfering domain of a child’s clinical picture warrants most immediate attention. That said, for those children who have more impairing diagnoses than SM, it may be important to address those concerns prior to targeting the SM behavior. In particular, for youth with significant oppositional or disruptive behavior, it is often recommended that parent management training focused on the child’s oppositional behaviors precede targeted SM treatment. For example, when treating a child with comorbid oppositional defiant disorder and SM, it can be wise to first complete a full course of traditional PCIT (which includes both CDI and Parent-Directed Interaction (PDI) skills focused on effective discipline and limit setting). Once the child’s oppositional behaviors have improved, the child may show more willingness and be in a stronger place to comply with exposure-based tasks focused on the SM (Carpenter et al., 2014; Mian, Godoy, Eisenhower, Heberle, & Carter, 2016). Similarly, if youth present with co-occurring depressive or mood disorders, and self-harm or clinical deterioration is a concern, it is advised that these more imminent matters be addressed first. For example, it may be wise to first emphasize behavioral activation and activity planning (Cornacchio, Sanchez, Chou, & Comer, 2017) in order to access additional social environments and have the child engage in more pleasurable and rewarding activities. Addressing mood symptoms first will also likely increase the child’s willingness to participate in exposure tasks as well as in the social interactions happening around them—even if nonverbally at first. Extensions of motivational interviewing (Dean, Britt, Bell, Stanley, & Collings, 2016) may also be incorporated for youth or parents who exhibit ambivalence about improving their situation or making needed changes.

Medication For some youth with SM, exposure-based therapies alone are insufficient, leaving families needing additional support. For older children II. Implementing exposure by diagnosis

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and adolescents who have had prior treatment with limited success, a medication consultation may be indicated. For more impaired cases of SM, selective serotonin-reuptake inhibitors and other associated antidepressants can be effective in decreasing the child’s anxiety enough to enable him or her to better enter into exposures and more fully benefit from behavior therapy. Few controlled studies have examined the efficacy of combining CBT and medication to specifically treat SM (Østergaard, 2018), but a growing body of literature more broadly supports such a multimodal approach for the treatment of more severe child anxiety (Taylor et al., 2018; Walkup et al., 2008). For example, in the large multisite Child Anxiety Multimodal Study (CAMS; Walkup et al., 2008), combination treatment was associated with an 81% acute response rate in the treatment of child anxiety, which was significantly better than the acute response rates associated with CBT alone (60%), antidepressants alone (55%), and pill placebo (24%). Although only a small proportion of the anxious children who participated in the CAMS trial had SM, these results nonetheless provide preliminary indication of the positive role that a combined treatment strategy may play in the treatment of some youth with SM.

Conclusion and future directions Despite SM being one of the more difficult anxiety disorders to treat, many strides have been made in recent years to improve the portfolio of effective treatment options for these youth struggling to find their voice in social situations. Exposure-based behavioral methods drawing on shaping, fading, reinforcement, and generalization are the most wellstudied and at this point and have shown the most evidence for reducing SM symptoms (Bergman et al., 2013; Cornacchio, Furr, Sanchez, et al., 2019; Hong et al., 2018 Muris & Ollendick, 2015; Østergaard, 2018). As exposure-based methods continue to show support for the treatment of SM, increased efforts will be needed to extend the reach of such methods. As is the case with all low base rate disorders requiring more specialized treatment methods (see Comer & Barlow, 2014), expertise in the treatment of SM is scarce, leaving many affected families without access to care. In recent years, an increasing number of SM specialty clinics have begun to offer intensive SM treatment options (see Carpenter et al., 2014; Cornacchio, Furr, Sanchez, et al.,2019; Hong et al., 2018) that allow families dwelling in regions without SM treatment expertise to travel to a specialty clinic to receive a course of SM treatment in a condensed single week. With increasing support for such intensive treatment models, comparative effectiveness trials will be needed to assess the relative merits of intensive group exposure therapy II. Implementing exposure by diagnosis

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models versus traditional weekly outpatient exposure therapy models, and to assess which of these formats is most indicated for which subpopulations of youth with SM. Multimodal treatment options that incorporate medication for the treatment of more severe SM must also undergo more systematic study. Despite the work needed ahead, research to date has provided very exciting support for the very positive effects of exposure-based treatments for the treatment of SM. Although historically misclassified, misunderstood, and poorly studied, children with SM now have a range of supported exposure therapy methods that have demonstrated promising utility in helping the youth find their voice across their home, academic, and social worlds.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: Author. Bergman, R. L., Gonzalez, A., Piacentini, J., & Keller, M. L. (2013). Integrated behavior therapy for selective mutism: A randomized controlled pilot study. Behaviour Research and Therapy, 51(10), 680 689. Available from https://doi.org/10.1016/j. brat.2013.07.003. Bergman, R. L., Piacentini, J., & McCracken, J. T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child & Adolescent Psychiatry, 41(8), 938 946. Available from https://doi.org/10.1097/ 00004583-200208000-00012. Bogels, S. M., Alden, L., Beidel, D. C., Clark, L. A., Pine, D. S., Stein, M. B., & Voncken, M. (2010). Social anxiety disorder: Questions and answers for the DSM-V. Depression and Anxiety, 27, 168 189. Available from https://doi.org/10.1002/da.20670. Carpenter, A. L., Puliafico, A. C., Kurtz, S. M. S., Pincus, D. B., & Comer, J. S. (2014). Working from home: An initial pilot examination of videoconferencing-based cognitive behavioral therapy for anxious youth delivered to the home setting. Clinical Child and Family Psychology Review, 17, 340 356. Available from https://doi.org/10.1007/s10567-0140172-4. Chavira, D. A., Shipon-Blum, E., Hitchcock, C., Cohan, S., & Stein, M. B. (2007). Selective mutism and social anxiety disorder: All in the family? Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1464 1472. Available from https://doi.org/ 10.1097/chi.0b013e318149366a. Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with selective mutism: A critical evaluation of the literature from 1990-2005. Journal of Child Psychology and Psychiatry, 47, 1085 1097. Available from https://doi.org/10.1111/j.1469-7610.2006.01662.x. Comer, J. S., & Barlow, D. H. (2014). The occasional case against broad dissemination and implementation: Retaining a role for specialty care in the delivery of psychological treatments. American Psychologist, 69, 1 18. Available from https://doi.org/10.1037/ a0033582. Comer, J. S., Furr, J. M., Cooper-Vince, C., Madigan, R. J., Chow, C., Chan, P. T., . . . Eyberg, S. M. (2015). Rationale and considerations for the Internet-based delivery of Parent-Child Interaction Therapy. Cognitive and Behavioral Practice, 22, 302 316. Available from https://doi.org/10.1016/j.cbpra.2014.07.003.

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Comer, J. S., Furr, J. M., Miguel, E., Cooper-Vince, C. E., Carpenter, A. L., Elkins, R. M., . . . Chase, R. (2017). Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered Parent-Child Interaction Therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85, 909 917. Available from https://doi. org/10.1037/ccp0000230. Comer, J. S., & Myers, K. M. (2016). Future directions in the use of telemental health to improve the accessibility and quality of children’s mental health services. Journal of Child and Adolescent Psychopharmacology, 26, 296 300. Available from https://doi.org/ 10.1089/cap.2015.0079. Comer, J. S., Puliafico, A. C., Aschenbrand, S. G., McKnight, K., Robin, J. A., Goldfine, M., & Albano, A. M. (2012). A pilot feasibility evaluation of the CALM program for anxiety disorders in early childhood. Journal of Anxiety Disorders, 26, 40 49. Available from https://doi.org/10.1016/j.janxdis.2011.08.011. Cornacchio, D., Furr, J.M., Sanchez, A.L., Hong, N., Feinberg, L., Tenenbaum, R. & Comer, J.S. Intensive group behavioral treatment (IGBT) for children with selective mutism: A preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology 87, 2019, 720-733. Available from: https://doi.org/10.1037/ccp0000422. Cornacchio, D., Sanchez, A. L., Chou, T., & Comer, J. S. (2017). Cognitive-behavioral therapy for children and adolescents. In S. G. Hofmann, & G. Asmundson (Eds.), The science of cognitive behavioral therapy: From theory to therapy. New York, pp. 257 288: Elsevier. Available from 10.1016/B978-0-12-803457-6.00011-8. Cunningham, C. E., McHolm, A. E., & Boyle, M. H. (2006). Social phobia, anxiety, oppositional behavior, social skills, and self-concept in children with specific selective mutism, generalized selective mutism, and community controls. European Child and Adolescent Psychiatry, 15(5), 245 255. Available from https://doi.org/10.1007/s00787-006-0529-4. Dean, S., Britt, E., Bell, E., Stanley, J., & Collings, S. (2016). Motivational interviewing to enhance adolescent mental health treatment engagement: A randomized clinical trial. Psychological Medicine, 46, 1961 1969. Available from https://doi.org/10.1017/ S0033291716000568. Elizur, Y., & Perednik, R. (2003). Prevalence and description of selective mutism in immigrant and native families: A controlled study. Journal of the American Academy of Child & Adolescent Psychiatry, 42(12), 1451 1459. Available from https://doi.org/10.1097/ 00004583-200312000-00012. Eyberg, S. M., & Funderburk, B. (2011). Parent-child interaction therapy protocol. Gainesville, FL: PCIT International. Hong, N., Cornacchio, D., Furr, J.M., & Comer, J.S. (2018). Utilizing observational measures to evaluate the efficacy of intensive group behavior therapy for children with selective mutism. Poster presented at the annual convention of the Association for Behavioral and Cognitive Therapies, Washington, D.C. Kristensen, H. (2000). Selective mutism and comorbidity with developmental disorder/ delay, anxiety disorder, and elimination disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39(2), 249 256. Available from https://doi.org/ 10.1097/00004583-200002000-00026. Kumpulainen, K., Ra¨sa¨nen, E., Raaska, H., & Somppi, V. (1998). Selective mutism among second-graders in elementary school. European Child and Adolescent Psychiatry, 7, 24 29. Available from https://doi.org/10.1007/s007870050041. Kurtz, S.M.S., Comer, J., & Masty, J. (2007). Selective mutism interaction coding system revised (unpublished manuscript). Masty, J.K., Kurtz, S.M.S., Tryon, W.W., & Gallagher, R. (2009, March). Conditional probabilities of selectively mute children responding to parental questions. Poster session presented at the meeting of the Anxiety Disorders Association of America, Santa Ana Pueblo, NM. Mian, N. D., Godoy, L., Eisenhower, A. S., Heberle, A. E., & Carter, A. S. (2016). Prevention services for externalizing and anxiety symptoms in low-income children: The role of parent

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preferences in early childhood. Prevention Science, 17, 83 92. Available from https://doi. org/10.1007/s11121-015-0601-8. Muris, P., & Ollendick, T. H. (2015). Children who are anxious in silence: A review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review, 18(2), 151 169. Available from https://doi.org/10.1007/s10567-015-0181-y. Oerbeck, B., Overgaard, K. R., Stein, M. B., Pripp, A. H., & Kristensen, H. (2018). Treatment of selective mutism: A 5-year follow-up study. European Child and Adolescent Psychiatry, 27, 997 1009. Available from https://doi.org/10.1007/s00787-018-1110-7. Oerbeck, B., Stein, M. B., Pripp, A. H., & Kristensen, H. (2015). Selective mutism: Followup study 1 year after end of treatment. European Child and Adolescent Psychiatry, 24(7), 757 766. Available from https://doi.org/10.1007/s00787-014-0620-1. Østergaard, K. R. (2018). Treatment of selective mutism based on cognitive behavioural therapy, psychopharmacology and combination therapy—A systematic review. Nordic Journal of Psychiatry, 72, 240 250. Available from https://doi.org/10.1080/08039488.2018.1439530. Remschmidt, H., Poller, M., Herpertz-Dahlmann, B., Hennighausen, K., & Gutenbrunner, C. (2001). A follow-up study of 45 patients with elective mutism. European Archives of Psychiatry and Clinical Neuroscience, 251, 284 296. Available from https://doi.org/ 10.1007/PL00007547. Silverman, W. K., & Barlow, D. H. (1996). Manual for the ADIS-IV-C/P. New York, NY: Psychological Corporation. Steinhausen, H. C., & Juzi, C. (1996). Elective mutism: an analysis of 100 cases. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 606 614. Available from https://doi.org/10.1097/00004583-199605000-00015. Taylor, J. H., Lebowitz, E. R., Jakubovski, E., Coughlin, C. G., Silverman, W. K., & Bloch, M. H. (2018). Monotherapy insufficient in severe anxiety? Predictors and moderators in the child/adolescent anxiety multimodal study. Journal of Clinical Child and Adolescent Psychology, 47, 266 281. Available from https://doi.org/10.1080/15374416.2017.1371028. Toppelberg, C. O., Tabors, P., Coggins, A., Lum, K., Burger, C., & Jellinek, M. S. (2005). Differential diagnosis of selective mutism in bilingual children. Journal of the American Academy of Child and Adolescent Psychiatry, 44(6), 592 595. Available from https://doi. org/10.1097/01.chi.0000157549.87078.f8. Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical Psychology Review, 29(1), 57 67. Available from https://doi. org/10.1016/j.cpr.2008.09.009. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 2753 2766. Available from https://doi.org/10.1056/NEJMoa0804633.

Further reading Bergman, R. L., Keller, M. L., Piacentini, J., & Bergman, A. J. (2008). The development and psychometric properties of the selective mutism questionnaire. Journal of Clinical Child & Adolescent Psychology, 37(2), 456 464. Available from https://doi.org/10.1080/ 15374410801955805.

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7 Exposure therapy for separation anxiety disorder Kara B. West, Joanie Wilbanks and Cynthia Suveg Psychology Department, University of Georgia, Athens, GA, United States

Exposure therapy for separation anxiety disorder Separation anxiety disorder (SAD) is one of the most prevalent anxiety disorders in children and adolescents (Beesdo, Knappe, & Pine, 2009). CBT is a gold-standard treatment for youth SAD (e.g., Reynolds, Wilson, Austin, & Hooper, 2012) and includes psychoeducation (e.g., explanation and normalizing of anxiety), development of coping skills (e.g., relaxation techniques and cognitive restructuring), and exposure tasks (Kendall & Hedtke, 2006; Shortt, Barrett, & Fox, 2001). These components often occur together and generally follow the sequence listed above; however, in this chapter, we focus on exposure therapy as a stand-alone treatment, while recognizing that exposures are often delivered in tandem with other behavioral and cognitive techniques. Given that family involvement is critical when treating SAD in youth, issues related to family involvement are integrated throughout the chapter. First, we provide an overview of SAD and the rationale, description, and implementation of exposure therapy for treating SAD in youth. Second, we discuss developmental (e.g., cognitive and emotional development) and cultural factors that should be considered when delivering exposure therapy. We emphasize the discussion of cultural factors here as developmental factors are often addressed in treatment packages that include exposure therapy (e.g., Coping Cat; Kendall et al., 2005). Third, we consider challenging issues in the treatment of youth with SAD, including youth resistance, parental attitudes and behaviors, and clinician discomfort. Finally, we conclude this chapter with a discussion of

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ethical issues that should be considered when delivering exposure therapy with youth.

What is separation anxiety disorder? SAD is one of the most prevalent anxiety disorders in children (3.9%) and adolescents (2.3%; Costello, Egger, Copeland, Erkanli, & Angold, 2011), with a slightly higher prevalence rate among females (Masi, Mucci, & Millepiedi, 2001). According to Diagnostic and Statistical Manual of Mental Disorders—Fifth edition (DSM-5), SAD is characterized by developmentally inappropriate and excessive anxiety concerning separation from home or others (American Psychiatric Association, 2013). In SAD, the excessive anxiety is accompanied by anticipatory anxiety and avoidant behaviors that may present as reluctance or refusal to separate from the attachment figure (e.g., anger or protesting separation; Masi et al., 2001). For example, youth with SAD may excessively worry about an attachment figure dying or becoming ill, or experience distress and reluctance when separation from an attachment figure is anticipated (e.g., going to school, bedtime). Youth with SAD may suffer from repeated nightmares involving themes of separation, or complain of physical symptoms (e.g., headache, stomachache, nausea) when separation occurs or is anticipated. To meet diagnostic criteria for SAD, the excessive worry and avoidance behaviors must cause significant distress or impairment in important areas of functioning (e.g., school, social; American Psychiatric Association, 2013). Developmental differences have been reported in the presentation of symptoms—younger children, ages 5 8 years, most often report unrealistic worry about harm befalling an attachment figure and school refusal, whereas older children, ages 9 12 years, most often report distress at the time of separation. Somatic complaints and school refusal are very common in adolescents. SAD should be distinguished from developmentally appropriate separation distress that occurs in early childhood, but gradually subsides around 3 5 years of age. For some children, developmentally normative separation distress may subside and then return later on in childhood as SAD; whereas for others, the developmentally appropriate distress continues throughout childhood until it is no longer normative, meeting criteria for SAD. The mean age of onset for SAD is about 7.5 years of age, and longitudinal research finds that the average duration of SAD is approximately 3.5 years (Lewinsohn, Holm-Denoma, Small, Seeley, & Joiner, 2008). SAD in childhood is most often associated with school refusal, with approximately 75% of children with SAD reporting persistent unwillingness to attend school (Masi et al., 2001). The prognosis of youth with

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SAD is highly variable, with many youth experiencing distress and impairment into adulthood (Lewinsohn et al., 2008). SAD in childhood is associated with increased risk for psychopathology in adulthood, especially other anxiety disorders (e.g., panic disorder) and depressive disorders (Lewinsohn et al., 2008). Lewinsohn et al. (2008) found that 73.5% of individuals diagnosed with SAD during childhood developed another form of psychopathology in adulthood, even if they recovered from SAD during childhood, further highlighting the risk of childhood SAD. Consequently, timely treatment for SAD is imperative.

What is exposure therapy? Description and rationale Exposure therapy involves exposing the child to feared stimuli or anxiety-provoking situations. Theoretically, through repeated exposures to feared stimuli or situations, anxiety decreases, and in some cases becomes extinct (Kendall et al., 2005). The mechanisms responsible for the decrease in anxiety likely involve a combination of counterconditioning, extinction, habituation, and cognitive change (e.g., McGuire & Storch, 2019; Waters & Pine, 2016). Regardless of the specific change mechanism, exposing youth to their fears while developing adaptive behavior in response to the feared situation is considered a critical component of therapy for anxious youth (Whiteside et al., 2015). Importantly, complete extinction of anxiety is not expected; rather, the goal is to reduce anxiety such that it no longer causes the youth and family distress and impairment and to improve the youngster’s ability to adaptively cope with anxious triggers. Anxiety may also temporarily get worse before it gets better, as youth are asked to face the exact fear they have been avoiding and parents gain experience tolerating youth’s distress. Relapse or periods of increased anxiety after treatment should likewise be expected (Fisak, Richard, & Mann, 2011). These expectations should be made clear to youth and their family at the start of treatment, as unrealistic or exceptionally high expectations may lead to discouragement and frustration (Drake & Ginsburg, 2012). Due to the developmental timing and nature of SAD, family involvement in exposure therapy for SAD is necessary (Rudy, Zavrou, Johnco, Storch, & Lewin, 2017). Treatment often only occurs hourly, once a week, with the remaining bulk of youth’s time spent in school with peers or with family. Parents have a unique opportunity to serve as reinforcers of material and skills learned in therapy and can facilitate engagement in out-of-session exposures. Thus, it is critical that parents are involved in treatment so they may serve as “coaches” both inside

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and outside of the therapy room. In addition to teaching parents and other family members to serve as coaches during the therapy process, the clinician should take ample time to help parents develop an understanding of separation anxiety. This involves education about separation anxiety, normalizing the parents’ concerns, and addressing any misconceptions. Relatedly, parents may express feelings of guilt and frustration, and wonder what they did wrong or why their child suffers from anxiety. Clinicians should not ignore this and instead, should take a supportive and collaborative stance from the beginning of treatment, validating the parents’ concerns and anxieties, addressing any blame between family members, and instilling hope with the goal of setting a positive stage for treatment (Eisen & Schaefer, 2005). Genetic and environmental factors that underlie the development and maintenance of SAD further underscore the importance of taking a family approach to treatment (e.g., Murray, Creswell, & Cooper, 2009). Considering child anxiety more broadly, etiological models emphasize the reciprocal relation between parent and child anxious behavior; anxious children are more likely to have anxious parents (e.g., characterized by over-involvement, control, and protection; Hudson & Rapee, 2004; Rapee, 2012). This is likely due to a combination of genetic vulnerabilities (e.g., behaviorally inhibited temperament, heightened stress response), coupled with modeling and reinforcement of anxious behavior and avoidance of anxiety-provoking situations (Breinholst, Esbjorn, Reinholdt-Dunne, & Stallard, 2012; Wood, McLeod, Sigman, Hwang, & Chu, 2003). Although parents of youth with SAD may not have suffered from SAD or another anxiety disorder as youth, anxious behaviors and cognitions may be passed from the parent to child unintentionally and confer risk for anxiety problems more broadly. For example, a mother may frequently remind her child how important it is to stay near her when they are out of house (e.g., at the grocery store, public park, or mall) because children get kidnaped. The mother is trying to keep her child safe, but this may convey a different message to the child—“I am not safe when I am away from my mother.” By involving parents in exposure therapy, parents can understand how their behavior impacts their child’s anxiety and thus reduce behaviors that reinforce and maintain their child’s anxiety and increase behaviors that support developmentally appropriate levels of independence.

Types of exposure tasks Exposures tasks can be broken down into two overarching categories: imaginal or in vivo. During imaginal exposures, the child imagines that he is in the presence of the feared stimuli or situation. Imaginal

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exposures can be incredibly valuable in the treatment of SAD, as in vivo exposures are sometimes impossible to implement (e.g., family member dying or becoming ill). Imaginal exposure tasks can also be a great way to ease the child into exposures and allow the child an opportunity to practice coping skills before facing the feared situation “in real life.” For example, imaginal exposures for youth with SAD may involve the child role-playing separating from their parent using toys or writing a story about their parent dropping them off at school and reading it aloud to the clinician (Kendall et al., 2005). In vivo exposures involve actual exposure to the feared situation and can be tailored to make them more or less challenging/fearful. For example, in vivo exposures for youth with SAD may involve the parent or attachment figure standing outside of the therapy building or the parent driving around the neighborhood while the child is inside with the clinician. Although the examples mentioned thus far are typically conducted in the therapy session, out-ofsession exposures are very valuable in the treatment of SAD. Clinicians should discuss the importance of practicing outside of session with youth and their parents, and each week select at least one specific exposure that the youth will complete before the next session.

Features of the exposure task How to create a fear and avoidance hierarchy In order to implement exposures effectively, it is important to accurately assess what triggers youth’s anxiety and distress. It is especially critical that the clinician does not assume which situations may be fearful to the youth, but rather the clinician should assess a variety of situations, discuss with the youth and parents which situations are most fearful, and what the youth expects to happen in feared situations. Collaboratively, the clinician, the youth, and his/her parents should work together to develop a list of specific feared situations (see Fig. 7.1 for a sample hierarchy). It is important to identify a wide range of feared situations that vary in level of difficulty, based on the child’s subjective fear. The fear hierarchy should be considered a work in progress and continually updated throughout treatment. Depending on the age and developmental maturity of the child or adolescent, the clinician and parents may need to help the youth identify fearful situations. For example, if a child says, “when my mom leaves,” the clinician and parents can help the child be more specific: “when my mom drops me off at school,” “when my mom leaves me at home to go to the grocery store,” or “when my mom goes into a different room than me at home.” Relatedly, some youth may have low insight into their anxiety

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FIGURE 7.1 Sample hierarchy for child with separation anxiety disorder (SAD) with particular anxiety about separating at school. Note that at the start of treatment the child in this example has mother drop him off and pick him up from school each day and the child calls home frequently during the school day.

symptoms and report that they do not experience any anxiety in response to parental separation. Parents may need to prompt the youth by saying, “Remember last week when I dropped you off at soccer practice?” to help the youth consider concrete situations in which they previously experienced separation anxiety. If the youth continues to deny feelings of anxiety, the clinician could suggest they add the situation to the hierarchy and “try it out” as one of the early exposures. Once a list of feared situations has been developed, the child will sort the situations into “easy,” “medium,” and “hard” depending on the child’s subjective fear level for each situation.

How to use subjective units of distress After developing a list of feared situations and sorting them into “easy,” “medium,” and “hard,” the next step is having the child rate

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how anxiety-provoking each situation is using a Likert-type scale called subjective units of distress (SUDs; Wolpe, 1969). Visual aids are often used to help explain the SUDs system and may be referred to as a “worry/fear thermometer.” It is helpful to include a brief descriptor next to each number, such as “easy peasy” for 0 and “the absolute scariest” for 8. Additionally, the clinician should engage the child in a conversation about what their anxiety might feel like at various numbers throughout the scale to help the child understand the range of the scale. Through this process, parents should be encouraged to provide suggestions and examples of situations in which the child has demonstrated or reported varying levels of anxiety, and the clinician should foster a collaborative environment where everyone present in the session feels included in the discussion and activity. Next, the child will go through their previously developed hierarchy and assign a SUDs rating to each situation based on how anxiety-provoking the situation is to the child (see Fig. 7.1 for sample hierarchy with SUDs). Although the ratings are based on the child’s subjective perception of fear (or distress), the clinician and parents will often help guide the child, especially if the child has low insight into their anxiety symptoms (e.g., thinks every situation is the scariest, or no situations are scary). Having previously sorted the situations into “easy,” “medium,” and “hard” should help with this step. Again, parents input and suggestions are valuable during this step, as they have observed their child in a variety of situations at varying levels of difficulty. Once the situations have been rated, the exposures should be written in a hierarchical order, with the least anxiety-provoking situation at the bottom so that youth can visualize how they will progress up the hierarchy throughout treatment. In addition to rating situations on the hierarchy, SUDs can also be obtained when carrying out an exposure task.

How to carry out an exposure Once the hierarchy is made and SUDs have been assigned, youth are ready to begin exposures. Table 7.1 provides a general step-by-step guide for carrying out an exposure. It should be noted that treatment rarely, if ever, begins with exposures without teaching youth coping skills ahead of time.

Before the exposure The first step in preparing for an exposure task is to select an exposure task from the hierarchy to complete. It is advised that the first

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TABLE 7.1 Step-by-step guide to exposure therapy for youth with separation anxiety disorder (SAD). 1. The clinician identifies an exposure task, solicits feedback from the child and parents, and discusses until everyone comes to an agreement. 2. The clinician, child, and parents negotiate a reward for completion of the exposure task (if applicable). 3. The clinician, child, and parents collaboratively discuss and develop a plan for coping with anxiety during the exposure task. Solicit information about: a. Specific aspects of the task the child anticipates being particularly difficult b. Expected feelings c. Somatic reactions d. Anxious self-talk 4. The clinician, child, and parents collaboratively problem-solve how the child will cope with the aspects of the task identified as potentially difficult. 5. The child provides a SUDs rating prior to the exposure. 6. The exposure begins. a. The clinician refrains from allowing the child to engage in avoidance, including subtle avoidance behaviors (e.g., safety-seeking behaviors). b. The child provides SUDs rating approximately every 2 min during the exposure. c. The clinician records each SUDs rating and also provides a rating for perceived anxiety experienced by the child at each SUDs rating point (i.e., preexposure, during exposure, postexposure). 7. The clinicians terminate the exposure when the child’s SUDs decrease by half. 8. The clinician, child, and parents process the child’s experience of completing the exposure task. 9. The clinician and/or parent rewards the client for effort and completion of the exposure task. 10. At least one out-of-session exposure task for homework is collaboratively decided upon and discussed.

exposure is chosen from the bottom, or less anxiety-provoking, end of the hierarchy because youth and parents may be hesitant to begin exposures. Additionally, choosing an exposure from the lower end of the hierarchy will allow the child to gain a sense of self-efficacy and motivation. Regardless, it is not uncommon for youth to express resistance or distress prior to an exposure. The clinician and parents can develop a reward system ahead of time to increase youth compliance and motivation. Once the exposure task has been selected and agreed upon, the clinician will prepare the child and parents for the exposure. Preparing the child and parents typically involves the clinician soliciting information about what specific aspects of the exposure task the child and parents anticipate being most difficult, as well as expected feelings, somatic reactions, and anxious self-talk. The clinician should also work with the child to explicitly define what the child is afraid of happening upon separation from his/her parents. For example, a child might fear something bad will happen to herself when separated from mom.

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The clinician should specify, with the child, exactly what “something bad” might be, so that after the exposure the clinician can ask the child if the feared outcome occurred. Designing exposures to challenge youths’ expectancies (i.e., expectancy violation), and reflecting on the expectancy violation as part of postexposure processing, is one process thought to facilitate learning and anxiety reduction overtime (McGuire & Storch, 2019). Next, the clinician, child, and parents collaboratively problem-solve how the child will cope with aspects of the task identified as potentially difficult, and the clinician and parents may model coping strategies (e.g., coping statements). The clinician and parents can use this opportunity to remind the child that it is expected that the child will feel nervous before and during an exposure, while highlighting that the child has the skills and ability to face the feared situation. It is important that the clinician and parents do not provide reassurance in response to the child’s fears thereby reinforcing the child’s anxiety. For example, in response to a child’s distress, the parents could say, “You can do this! Let’s review some of the coping skills you have learned that you can use in this situation,” instead of a reassuring response, “Don’t worry, we will be right outside of the room,” or providing excessive attention which reinforces the child’s distress. Relatedly, the clinician should prepare the parents for the exposure and emphasize the importance of their behavior and reactions about the exposure. Unlike exposures for most other anxiety disorders where parent involvement in exposures is common, the parent will likely not be physically present during the delivery of the exposure for youth with SAD. However, their attitudes about the exposure task may be conveyed to the child and should not reinforce, reassure, or encourage avoidance of the anxiety. Once both the child and parents have been prepared, the clinician should ensure understanding of the exposure task. For example, the clinician might say, “In a minute, your mom and dad are going to walk out of the room while you and I stay in here.” As the child advances through exposure therapy, the clinician progresses toward leaving the child in the room alone. Right before the exposure begins, the clinician should ask the child to rate their SUDs at the moment, while also recording the clinician’s own assessment of the child’s SUDs. At this time, the parents are instructed to leave the room.

Implementing the exposure It is important to ensure that the child is engaged in the exposure, not engaging in safety-seeking behaviors (SSB; e.g., texting the parent, asking the therapist for reassurance, trying to escape the situation, repeatedly asking how much time is left). SSBs function to increase

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feelings of safety in the presence of perceived threat and facilitate avoidance, escape, and/or distraction, whereas coping behaviors (e.g., challenging anxious thoughts, coping self-talk) function to help manage feelings of anxiety (Hedtke, Kendall, & Tiwari, 2009). Research finds that youth who consistently engage in SSBs, as opposed to coping behaviors, experience poorer outcomes in exposure therapy (e.g., less reduction in anxiety; Hedtke et al., 2009). Early in the course of exposure therapy, depending on the severity of anxiety and the child’s age, the clinician may allow the child to distract themselves by playing with a toy or drawing. However, as youth progress through therapy, clinicians should try to encourage the child to use coping skills, “What is a coping skill you could use right now to feel better?” and provide suggestions if necessary (e.g., coping statements). Attempts to reassure the child should be minimized; however, the clinician may need to provide prompts if the youth tries to escape the exposure. The clinician should obtain SUDs ratings throughout the exposure (e.g., every 2 minutes), at a frequency that is not disrupting or distracting. The clinician should also provide their own assessment of the child’s anxiety throughout the exposure. These ratings may be used to track changes in anxiety both within a single exposure, as well as over the course of therapy, which is necessary information for the clinician. If the exposure was intended to be carried out until the child’s SUDs rating decreases by 50% from the first SUDs rating, it is critical that the clinician assesses SUDs ratings throughout the exposure. If the child initially reported a SUDs rating of 7 and after 15 minutes reports a SUDs rating of 3, the clinician should not immediately end the exposure, but rather wait another few minutes to provide more time for anxiety to dissipate. The clinician should be aware that the child may report lower SUDs in an attempt to escape or end the exposure; clinicians must use their judgment to determine if the child’s anxiety has decreased by 50%. Alternatively, if a significant amount of time has passed and the child is not reporting a 50% decrease in SUDs, the clinician should attend to physiological and behavioral indicators (e.g., sweating, shaking, posture, facial expression, white knuckling) to examine if the child appears to be less anxious. If the clinician observes a change in the child’s response from the start of the exposure, they may comment on this by saying, “I noticed that you were shaking when we first started, but now you are sitting still.” This may be especially helpful for youth who have difficulties identifying their emotions and related physiological and behavioral responses. However, if the child’s physiological and behavioral responses suggest that the child is still very anxious and their SUDs has not decreased, the clinician may elicit information from the child about their current experience by asking, “What are the things you are still worried about? What thoughts are you having?” and encourage use of coping skills. If

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the child is still reporting high levels of anxiety after a significant amount of time, the clinician may end the exposure and praise the child for their effort, emphasize the child’s ability to tolerate the distress, and note that this exposure will be repeated in the future. If the exposure was designed to terminate once the child’s expectancy was violated (e.g., “If mom leaves the room for 20 minutes, I will cry until she comes back”), the clinician might terminate the exposure shortly after the child stops crying. The goal here is to highlight to the child that his fear did not come true and he was able to tolerate and cope with the situation. Regardless of the method used to determine exposure termination, the ultimate goal is to highlight to the child that he was able to cope with the situation.

After the exposure As soon as the exposure ends, the clinician should obtain a SUDs rating from the child, as well as document their own assessment of the child’s anxiety levels. At this time, it is appropriate to bring the parents back into the therapy room so that the clinician can model for the parents how to process fearful situations with their child. The clinician and parents should immediately provide positive reinforcement to the child for completing the exposure by providing verbal praise, or for younger children, small tokens such as stickers. If a reward system was put in place before the exposure, the reward likely cannot be delivered immediately (e.g., sleepover with a friend, extra TV time, ice cream after dinner), so verbal praise and stickers can help bridge the gap of time between the exposure and the predetermined reward. The clinician and parents should also encourage the child to “self-reward,” recognizing and reflecting on the fact that they faced one of their fears. Next, it is important to process the exposure with the child, including but not limited to how the child felt throughout the task, how they coped with their anxiety, and/or if their expectancy was violated (Kendall et al., 2005; McGuire & Storch, 2019). Research suggests that postevent processing of the exposure is a very important component of the exposure process, even more so than preevent processing (Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013). This discussion should be used as an opportunity to identify what made the exposure easy or hard, what they learned from this experience, if their fear occurred, and how they would respond to the situation in the future, assuming they will face a similar one again. After processing the exposure, before the child and parents leave the therapy session, the clinician, child, and parents should collaboratively decide on at least one exposure task for the child and parent to complete over the next week.

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Youth factors Developmental level While chronological age may provide an approximate measure of an individual’s developmental level, clinicians are urged to assess and consider each child’s cognitive, social, and emotional skills and apply exposure treatment with appropriate adaptations (Kingery et al., 2006). For instance, additional psychoeducation tailored to the child’s developmental level should be provided for children and adolescents with deficits in emotion understanding (for a guide to developing children’s emotion understanding and awareness, see Southam-Gerow, 2013). For example, clinicians can help younger children learn about emotions by creating a collage of cartoons or playing a game where the child and the clinician act out different emotions. An adolescent, on the other hand, may prefer to use pictures from a magazine or favorite TV show to create a collage, or may be able to identify different examples of people displaying various emotions (e.g., a football coach expressing anger at a call the referee made, a young child excitedly opening gifts on his birthday). It is important to assess children’s cognitive skills as well, given that cognitive components (e.g., cognitive restructuring, positive coping thoughts) are involved throughout exposure therapy. Modifications to the cognitive component of treatment will likely be required for younger youth, as they likely do not have the same cognitive skills as adolescents and may have difficulties with metacognition and abstract thinking (Schneider & Lockl, 2002). For example, when identifying thoughts, clinicians may find it helpful to use more concrete tools (e.g., cartoons with thought bubbles) with younger children. Prior to beginning exposures, it is imperative that the youth understands the rationale for exposures (Kendall et al., 2005). Therefore, the clinician must carefully tailor the presentation of the treatment rationale to the developmental level of the child or adolescent. Younger children would likely benefit from a more simplistic explanation (e.g., “The only way to get over our fears is to face them! Things get less scary the more we practice.”) or a visual representation. Importantly, the level of cognitive functioning also affects youth’s focus during exposure tasks. Younger children are more oriented toward the present, thereby making it more difficult for them to tolerate the momentary discomfort of the exposure. Adolescents, on the other hand, are better able to think abstractly and understand that their discomfort is momentary and will subside, while also understanding that continued exposure to the feared situation will allow for a lesser degree of discomfort as exposures are completed. Regardless of how cognitive skills are taught or what specific skills are

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emphasized in treatment, children with lower cognitive functioning will benefit from more time to process information and for skills to generalize to other settings and situations. Developmental considerations are particularly important for the selection of exposures, given that exposure tasks require the integration of all of the other skills the child has acquired through therapy (e.g., coping thoughts). As such, awareness of youth’s level of development informs how the clinician adapts exposures. Younger children have limited insight and therefore have difficulty predicting their level of anxiety in a given situation, which might result in inaccurate placement of exposures on the hierarchy. Additionally, some children may not be able to identify situations to include on the hierarchy themselves, and may benefit from the clinician and parents providing suggestions of potential anxietyprovoking situations. Depending on the nature of the exposure, it is important for the clinician to consider whether the child has the necessary social and emotional skills to complete such exposures. For example, if a child is to engage in an exposure that will put him in a situation where he will need to appropriately interact with others (e.g., separate from parent at the playground and play with other children), the clinician must ensure that the child possesses the necessary social skills (e.g., how to greet others, start a conversation, respond to others, share and take turns) and teach those skills prior to the exposure if the child lacks them.

Cultural considerations Parental control has been associated with youth anxiety; however, research finds that parenting consisting of high control may be more normative and adaptive for some cultural groups (e.g., Mexican American; Luis, Varela, & Moore, 2008; Varela & Hensley-Maloney, 2009). Given that differences in parenting and relations to youth anxiety exist across cultures, clinicians should consider the cultural role of parenting behaviors in youth’s anxiety and treatment. Additionally, prior research suggests that anxiety may manifest itself differently across cultural groups. Regarding SAD, not only are there cross-cultural differences in expectations for child separation and individuation, but youth from some cultural groups (e.g., Latino) are more likely to exhibit somatic symptoms of anxiety (e.g., headaches, stomachaches) than their European American counterparts (e.g., Pina & Silverman, 2004). Likewise, some cultural groups (e.g., Puerto Rican) may attribute physiological symptoms of anxiety to medical causes (Sood, Mendez, & Kendall, 2012). Consequently, it is important for clinicians to not only provide psychoeducation to parents, but to gather and incorporate information about parents’ beliefs and goals for treatment.

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Challenging issues Youth resistance Youth may attempt to resist exposures both overtly (e.g., crying, screaming, refusal, fleeing from the exposure) and covertly (e.g., identifying an “easy” exposure as “difficult”). While there are a number of ways a clinician can attempt to avoid such overt disruptive behaviors (e.g., beginning with less anxiety-provoking exposures), often such reactions are unavoidable. For example, due to the distressing nature of exposures, youth might cry. Clinicians should respond supportively, (e.g., “I know this is difficult. You’re doing a great job.”), while not providing reassurance. If it seems that the youth is particularly distressed, the clinician should use their judgment to determine if, perhaps, the exposure was not appropriate for that stage of treatment. More likely, however, is that the youth’s distress is a common reaction to exposure tasks, particularly at the start of treatment. In the case of more noncompliant (e.g., refusal, fleeing the exposure) rather than disruptive behaviors, tactics such as negotiation of the nature or duration of the exposure task and identification of appropriate rewards might prove useful. These responses to youth resistance are described in more detail below. Negotiation about exposures can be helpful in the context of youth resistance but clinicians and parents must exercise caution to avoid falling into the “negotiation trap” (Kendall et al., 2005, pp. 142 143) that results when a youth selects exposures that are not challenging or claims that a proposed exposure is too easy in an effort to avoid it. To avoid the negotiation trap, clinicians can identify several possible exposures and allow the youth to choose from those identified. Additionally, reminders of the rewards the youth will earn for effort in completing the exposure task can help encourage the youth to agree to complete the task. In some cases, it may be difficult to identify appropriate rewards for some youth, particularly if the parents typically allow the youth access to items and situations they value, therefore making these items less of a true reward or privilege. For example, a youth may already be allowed screen time (e.g., television, video games, tablet) whenever he desires. In cases such as this, clinicians can encourage parents to restrict access to such activities and, instead, use them as rewards. Rewards should correspond to the difficulty level of the exposure, with larger, more desirable rewards being reserved for the most difficult exposure tasks. Examples of small, medium, and larger rewards for younger children might be allowing the child to stay up 15 extra minutes one night, allowing the child to choose what movie the family watches one night, and having a friend sleepover, respectively.

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For adolescents, examples of small, medium, and larger rewards might be allowing an extra half hour of screen time, allowing a few friends to sleepover, and “get out of chore” passes, respectively. Ideally, rewards should require minimal, if any, financial expenditure on the behalf of the parents or clinician, and when collaboratively brainstorming rewards with parents, clinicians should suggest nonmonetary rewards. Rewards that require financial expenditure may not be reasonable for many families and are not sustainable over time. In the context of youth resistance, it can also be helpful to find ways to give the youth a sense of control. For example, if the exposure task is to leave the office with the clinician while the child’s mother waits in the waiting room, the clinician can provide the child with different destination options that are an equal distance from the building. Clinicians can also incorporate the interests of the youth into treatment to ward off resistance. For example, a clinician working with a 12-year-old who enjoys soccer might ask the adolescent to imagine coping thoughts that her favorite soccer player might use in distressing situations, such as before a big game. Additionally, the clinician might identify relevant rewards pertaining to the adolescent’s interest in soccer (e.g., kick the soccer ball around with the clinician at the end of session, receive a new soccer ball at the end of treatment) or create relevant exposures (e.g., ride with a friend to soccer practice rather than with parent). Resistance can also take the form of not completing out-of-session exposure tasks. For example, the youth and parent might report that they did not complete the exposure for the youth to walk to the bus stop while the parent watched from home due to rain, which resulted in the need for the parent to drive the youth to the bus stop. In such instances, it is important for the clinician to assess whether noncompliance, on the part of the youth and/or parent, is a result of events that are beyond the control of the parent or youth (e.g., youth illness preventing them from attending school) or is an act of avoidance. Early in treatment, it can be helpful for the clinician to review principles of operant conditioning (e.g., ignoring undesirable behavior, positive reinforcement; see Kazdin, 2008) with the parent. For instance, the clinician can review with the parents before exposure sessions begin that distress is likely and that the parent should remain neutral in those situations and be careful not to reinforce the youth’s anxiety.

Parental attitudes and behaviors Parent behaviors can also impede treatment progress by reinforcing the youth’s avoidant behaviors and consequently, their anxiety. For instance, parents may not be able to tolerate the distress they experience

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seeing their children in distress. Additionally, anxious parents in particular may have skewed interpretations of what kinds of situations are developmentally appropriate for their children and, thus resist including necessary exposures in their youth’s hierarchy (e.g., having a 10-year-old child ride the bus to school). Parents may likewise model anxious behavior themselves through verbal and/or behavioral demonstrations of anxiety, reinforcement, and/or accommodation of their youth’s anxiety, and biased threat information processing (Fisak & Grills-Taquechel, 2007). Such parent behaviors are likely to interfere with the treatment. Clinicians must provide a strong and clear rationale for exposure therapy and allow parents an opportunity to openly express their concerns. During in-session exposures, clinicians can help parents identify treatment-interfering parent behaviors, given that parents will need to encourage exposure tasks outside of therapy sessions. Open discussions with the parent about their thoughts and feelings will go a long way in facilitating parent collaboration.

Clinician discomfort Despite widespread support for exposure therapy in treating youth anxiety disorders, some clinicians may be hesitant or reluctant to begin exposure therapy for several reasons (Thomassin, Jones, & Suveg, 2017; Whiteside, Deacon, Benito, & Stewart, 2016). Prior research suggests that clinicians with exposure-related concerns do not appropriately deliver the treatment by permitting SSBs, providing reassurance, and terminating exposure tasks prematurely, leading to poorer treatment outcomes (Deacon, Lickel, Farrell, Kemp, & Hipol, 2013). Such clinicians will likely find it helpful to remind themselves of the benefits and efficacy of exposure therapy, and how the momentary discomfort leads to long-term improvements for the youth (Kendall et al., 2005). Clinicians new to exposure therapy should seek consultation to discuss their discomfort or other reservations with exposures so that they do not inadvertently interfere with successful exposure tasks.

Ethical considerations Exposure therapy has a history of objections due to unsubstantiated beliefs that exposure therapy is unsafe and unethical. When carried out correctly, exposure tasks have been shown to reduce the level of distress. However, inadequate or incompetent practice by the clinician can have negative effects on the youth and worsen the client’s symptoms (Gola, Beidas, Antinoro-Burke, Kratz, & Fingerhut, 2016). For example, exposure tasks that do not last long enough for SUDs ratings to

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decrease or the child’s expectation to be violated may actually increase the youth’s anxiety (Deacon et al., 2013). Clinicians in training, or clinicians new to exposure therapy should seek ongoing consultation and supervision throughout the implementation of exposures to ensure ethical and competent delivery of exposures (Thomassin et al., 2017); additional training resources exist online (e.g., training videos; for web links see Thomassin et al., 2017). Given the likelihood that some in-session exposures will need to occur outside of the walls of the therapy room, the clinician should make careful considerations of potential ethical concerns. First, taking the youth outside of the therapy room threatens the confidentiality, making it more likely that others will become aware of the clinician client relationship (American Psychological Association, 2010). Prior to such exposures, the clinician should discuss concerns about confidentiality with the youth, and brainstorm how the youth will respond if confronted by someone they know. Additionally, it is important that clinicians take appropriate steps to de-identify themselves (e.g., remove badges, refrain from overtly recording SUDs). Exposures will require the youth being in situations without a parent present (e.g., having an adolescent going to the mall without a parent). Although when conducted appropriately these exposure tasks have low levels of risk for the youth, clinicians must carefully consider the youth’s safety and developmental level when identifying and implementing exposure tasks (American Psychological Association, 2010). The clinician should always include both youth and parents in discussions about exposure tasks and address any concerns that may arise. Moreover, it is important for the clinician to view informed consent as an ongoing process, with the clinician describing each new exposure task and obtaining youth consent prior to each task (Thomassin et al., 2017). For a more thorough discussion of ethical issues related to therapy more broadly, and exposure tasks specifically, readers are referred to more comprehensive sources (American Psychological Association, 2010; Gola et al., 2016; Thomassin et al., 2017).

Discussion Separation anxiety is distressing and impairing for youth and their families. Fortunately, decades of research support the effectiveness of exposure therapy in treating youth with SAD. When treating youth with SAD, a collaborative, family-based approach is recommended, as parents and/or other attachment figures are central to the youth’s fear. Additionally, parents’ attitudes and behaviors may reinforce and maintain youth’s anxiety, further highlighting the benefit of including

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parents in treatment. Parents should be incorporated in all aspects of treatment, taking on the role of a “coach” and gradually assuming more responsibility, than the clinician, in and out of session. Considerable planning goes into preparing for exposure therapy, such as constructing a fear hierarchy, teaching youth how to rate their anxiety (i.e., SUDs), and psychoeducation and teaching of coping skills. These preparatory stages are incredibly helpful in carrying out exposure therapy and often increase youth and parent motivation and compliance, especially when done collaboratively. When delivering exposure therapy, it is not uncommon for the clinician to experience resistance and distress from youth and/or parents. It is important for clinicians to remind themselves, and youth and parents, of the rationale behind exposure therapy and to expect that youth’s anxiety may get worse before it gets better. Clinicians who find it difficult to tolerate this discomfort are encouraged to seek consultation and supervision. Additionally, cultural factors and ethical issues should be taken into consideration when delivering exposure therapy. In the past decade, researchers have strived toward a better understanding of exposure therapy, specifically which elements seem to make the most impact and which elements may be unnecessary. Preliminary research suggests that parent-coached exposures early in treatment are associated with greater improvement over fewer sessions (Whiteside et al., 2015) and that introducing exposures after teaching relaxation skills and anxiety management strategies may not be as critical as once believed (Ale, McCarthy, Rothschild, & Whiteside, 2015). However, these initial preparatory phases in therapy are associated with higher child-perceived therapeutic alliance (Whiteside et al., 2015). Relatedly, research efforts are currently focusing on enhancing our understanding of how parental involvement can have the greatest impact on outcomes, thereby improving the methods by which parents are incorporated in therapy (Breinholst et al., 2012; Taboas, McKay, Whiteside, & Storch, 2015). In sum, family-based exposure therapy is an effective, tolerable treatment for SAD in youth with long-lasting effects.

References Ale, C. M., McCarthy, D. M., Rothschild, L. M., & Whiteside, S. H. (2015). Components of cognitive behavioral therapy related to outcome in childhood anxiety disorders. Clinical Child and Family Psychology Review, 18, 240 251. Available from https://doi.org/ 10.1007/s10567-015-0184-8. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from ,http://www.apa.org/ethics/code/..

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C H A P T E R

8 Exposure therapy for specific phobias in children and adolescents Lynn Mobach, Ella Oar and Jennifer L. Hudson Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia

Specific fears, such as a fear of the dark, a fear of certain animals, or a fear of heights, are very common in children and adolescents (Ollendick, King, & Frary, 1989). In most cases, these childhood fears are a short-lived, normal part of development and do not cause any clinically significant interference or distress. However, for 10 22% of children and adolescents (Kessler, Chiu, Demler, & Walters, 2005; Muris & Merckelbach, 2000; Muris, Merckelbach, Mayer, & Prins, 2000; Ollendick, Hagopian, & King, 1997), these fears are severe and chronic and cause significant distress in daily life, warranting a diagnosis of specific phobia. Specific phobia is one of the most prevalent anxiety disorders in childhood and adolescence and, unlike popular thought, can be debilitating and can interfere with children’s and adolescent’s lives on a daily basis (Deacon, Lickel, & Abramowitz, 2008; Ollendick, Davis, & Sirbu, 2009). To be diagnosed with a specific phobia, a child must present with a marked fear of a specific object or situation, which is not in accordance with the actual danger posed by that object or situation [Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5), American Psychiatric Association (APA), 2013]. Exposure to the object or situation must trigger an immediate fear or anxiety response and the person must go out of their way to avoid the object or situation, or the person

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can only endure exposure with extreme distress. The specific fear must significantly interfere with daily functioning in the context of the home, school, and with friends and must have been present for at least 6 months. Additionally, DSM-5 specifies that the specific fear must not be better explained by any other mental health condition. For example, in the case of a specific phobia for contracting an illness/disease; considerations for differential diagnoses entail ruling out obsessive compulsive disorder as a better explanation of the fear. The DSM-5 further classifies specific phobia into five main types, which include (1) the animal type, including all animals and insects, (2) the natural environment type (NET), which include the dark, thunderstorms and lightning, water, and heights (3) the blood-injection injury (BII) type, which includes seeing blood, getting injections, and undergoing blood tests, (4) the situational type, which includes elevators, lifts, and other enclosed spaces, but also flying, and (5) the other type, which includes doctors or dentists, choking, vomiting, costumed characters, and contracting an illness or disease (APA, 2013).

Case example Lily, a young girl who has just turned 10 years old, presents with a specific fear of dogs. Lily’s parents are desperate for her to get rid of her fear of dogs, as it is getting harder and harder for the parents to get Lily out of the house. They have just moved into a neighborhood close to Lily’s school, where many of Lily’s schoolmates also live. However, there is a big problem with the new neighborhood: there are many families with dogs in the neighborhood and in their own street. Lily has never been really fond of dogs and was never one to run up to pat a dog. However, ever since they have moved to their new house, Lily has become extremely frightened of the possibility that she will encounter a dog on the streets when she goes out of the house and therefore often refuses to go to school, and/or over to a friend’s house. She will only go by car and her parents have to pick her up from all her activities. When Lily encounters a dog on the street she is completely seized by fear and starts to run. This response has placed Lily in danger on a number of occasions. For example, there was a time that she ran up on the streets in front of a moving car when a dog came out of one of the houses on their street.

Treatment plan I: assessment A thorough assessment is integral to the development of an effective treatment plan for a client with specific phobia and assists the clinician

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in achieving multiple goals. First, as specific fears are quite common in normally developing children, it is paramount to do a thorough assessment of the specific fear to be able to distinguish developmentally appropriate specific fears from debilitating, persisting specific fears (i.e., is the specific fear present at a clinical level). Second, a thorough assessment enables the clinician to look at differential diagnoses and possible other comorbid psychiatric disorders (e.g., other specific phobias, other anxiety or mood disorders) which should be taken into account when developing the treatment plan. Third, the clinician can determine the severity of the specific phobia. Fourth, the clinician can determine the nature and level of the fear, the catastrophic beliefs, and the level of behavioral avoidance. Lastly, a thorough assessment before starting the treatment provides the clinician with a benchmark to evaluate treatment outcomes (Oar, Farrell, & Ollendick, in press; Silverman & Ollendick, 2005). Evidence-based assessment for specific phobias in children and adolescents should be both multi-method and multi-informant (Ollendick & Davis, 2012; Silverman & Ollendick, 2005). Multi-method refers to using multiple methods, such as a clinical interview, additional questionnaires, and a behavioral assessment. Multi-informant refers to including information from multiple informants, such as both the parents and the child, and in some cases, it might be relevant to obtain information from the child’s teacher (Ollendick & Hersen, 1993). With both children and adolescents, it is important to gain the perspective of both the parents and the child; it is not unusual for younger children to give a low interference rating, while the parents give a high interference rating. For adolescents, it is not unusual for it to be the other way around (Rapee et al., in press). Below, we offer recommendations as to how to conduct an evidence-based assessment for specific phobias.

Clinical interview and additional questionnaires The first step in an evidence-based assessment for specific phobia is not unlike any other psychiatric disorder assessment; the clinician starts with a semi-structured clinical/diagnostic interview. The gold standard diagnostic interview for assessing anxiety in youth is the Anxiety Disorders Interview Schedule for the DSM-IV (there is no version yet for the DSM-V; ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS-IV has a child and parent version and assesses all major anxiety disorders, mood disorders, and provides screeners and additional modules for both externalizing disorders (e.g., attention-deficit/hyperactivity disorder) and other disorders (e.g., pervasive developmental disorders). Although all modules of the ADIS-IV-C/P can be administered

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independently, it is recommended that the full interview is completed with the child and the parent(s) separately (Ollendick & Davis, 2012) to thoroughly assess for the presence of any other comorbid disorders. Additionally, it is recommended that the clinician starts the clinical interview with an assessment of the broader family (psychiatric) history, family composition and background, and developmental history (e.g., milestones) to embed the interview within the wider context of the child and their family and to establish rapport with the child and parents (Ollendick & Davis, 2012; Ollendick & Shirk, 2011). A broad assessment is needed to be able to assess whether there are other comorbid anxiety, mood, or other disorders (e.g., externalizing or pervasive developmental disorders) present. Interestingly, the presence of other anxiety disorders has not been found to have a negative impact on specific phobia treatment outcome and it was even found that specific phobia treatment has been related to less symptoms in comorbid ¨ st, anxiety disorders (Mobach, Gould, & Hudson, in press; Ollendick, O Reuterskio¨ld, & Costa, 2010; Ryan, Strege, Oar, & Ollendick, 2017). However, other comorbid disorders may have an impact on treatment outcomes. For example, comorbid ADHD symptoms have been found to predict poorer treatment outcome for specific phobia (Halldorsdottir & Ollendick, 2016). It is highly recommended that the clinician asks detailed questions to gain a better understanding of the nature and severity of the child’s fear. Gathering precise information about the child’s fear is crucial for tailoring their treatment plan. Examples of questions for Lily could be: “What kind of dogs are you scared of, big/small, a specific color, a specific breed?” “Are there any times that you are able to be around dogs and not feel scared, e.g., on a leash or if they were in a different room in the house?” “What parts of a dog are you most afraid of (e.g., teeth, paws, head)?” “Are there any particular behaviors dogs have that make you scared, e.g., jumping, running, barking?” Furthermore, as exposure treatment is primarily focused on challenging the child’s catastrophic beliefs about the phobic object or situation the clinician should complete a functional analysis of the phobia to assess these catastrophic beliefs (Davis, 2006), maintaining factors, and factors that have evoked the fear. The clinician can ask a variety of questions to elicit the child’s core catastrophic belief (e.g., “Imagine that a dog is in the room with us now, what do you fear will happen?”). In the case of Lily, she might answer that she is afraid that the dog will jump up against her and bite her in the face. The clinician should then obtain ratings (on a scale from 0 to 10) of several aspects of the catastrophic belief that give an indication of the child’s threat expectancies: (1) a probability rating, indicating how likely it is that the belief would occur, (2) a severity rating, indicating how bad it would be if the catastrophic belief were to come true, and (3) a self-efficacy rating, indicating the

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¨ st & belief in the ability to cope with the fear (Ollendick et al., 2009; O Ollendick, 2001). With regards to precipitating factors, Lily does not report a negative incident with a dog in her past. The key maintaining factors are Lily’s avoidance and her parents’ accommodation of her fear. For example, her parents have stopped visiting family members and they drive her around by car. Alongside clinical interviews with the child and the parent(s), administration of questionnaires can give the clinician a more comprehensive picture of the child’s (subclinical) symptomology. Questionnaires can be administered to both the child and the parents and should be focused on the specific phobia, and other anxiety-related and psychopathological symptoms. We recommend administering a measure focused on the specific phobia (and other anxiety disorders), as well as a broad measure, focused on general psychopathological symptoms. With regards to specific phobia measures, there are some questionnaires available that focus on a particular specific phobia subtype (Silverman & Ollendick, 2008), such as the Spider Anxiety and Disgust Screening for Children (Klein, van Niekerk, Baartmans, Rinck, & Becker, 2017). Alternatively, another reliable and valid instrument that measures a range of fears is the Fear Survey Schedule for Children Revised (FSSC-R; Ollendick, 1983). The FSSC-R is a self-report questionnaire for youth (aged 7 16) on which they can rate 80 specific objects and situations on how fearful that would make them. The FSSC-R has both a child and a parent version. With regards to other general psychopathological symptoms, the clinician can choose from general anxiety measures and measures spanning the broader psychopathology spectrum. In the case of the former, the Spence Children’s Anxiety Scale (Spence, 1998), or revised Child Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000) are widely used, reliable, and valid instruments. In contrast to the SCAS, the RCADS also assesses depression symptoms. When the clinician wants to assess broader psychopathological symptoms, the Child Behavior Checklist (CBCL; Achenbach, 2001) or the Behavior Assessment System for Children (BASC; Reynolds, Kamphaus, & Vannest, 2011) are both good options. The CBCL and the BASC both focus on internalizing and externalizing symptoms and both scales have a parent and teacher version.

Behavioral assessment A behavioral assessment is a crucial component of the assessment phase for specific phobias. The Behavioral Assessment Task (BAT; Ollendick & Davis, 2012) is a standardized, controlled (exposure-based)

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behavioral assessment, which involves the child/adolescent approaching their phobic object or situation. For example, Lily might be asked to enter a room and pat a dog for 30 seconds. Children are advised that the task is voluntary and that they can stop at any time. The degree to which the child is able to engage with their feared object/situation provides an objective measure of avoidance. The BAT is scored based on the percentage of steps [e.g., open the door (Step 1), stand 2 m from the dog (Step 5), and pat the dog on the head for 30 seconds (Step 10)] the child is able to complete during the task (Ollendick & Davis, 2012). For example, Lily asked to stop the task after opening the door to the BAT room and seeing the dog (Step 1), hence she would score 10% for her BAT. The BAT gives the clinician objective information about the child’s complete phobic response (e.g., cognition, physiological, and behavioral), which cannot be obtained via clinical interviews and questionnaires. This information is crucial to treatment planning as it provides a foundation from which to build a graduated exposure hierarchy. The child’s behavior during the BAT gives an indication of the starting point for exposure and their ability to manage their anxiety when confronted with their feared object/situation. The clinician can also gain insight into of the amount of fear experienced by the child by asking them to rate their subjective units of distress (SUDs), for example on a scale from 0 to 10. The BAT can also give the clinician an indication of any safety behaviors that the child might use. Safety behaviors are behaviors that will alleviate the anxiety and distress caused by the phobic object/ situation in the short term. Examples of common safety behaviors for a child with a specific phobia are the presence of a parent or in Lily’s case, wearing a winter coat. Importantly, some safety behaviors may not express behaviorally (the child may distract him/herself by thinking about something else) and have to be prompted by the clinician: “Are you doing anything to make yourself less anxious/nervous now?.” Children may not always be aware of these safety behaviors and it may be a good idea to ask the parents about possible safety behaviors during the assessment phase. The clinician can choose to do the BAT on the same day as the initial assessment or on a separate visit. The latter is recommended, especially when the phobic stimulus is not readily available. The clinician can plan the BAT as a separate visit before treatment starts as part of the treatment planning. Just as with the actual exposure session(s), the clinician has to think about how they are going to arrange the phobic stimulus. When the phobic stimulus/situation is not readily available, the clinician has to be creative. For example, in the case of a phobia for thunderstorms or lightning, the clinician can choose to let the child enter a dark room with a video and sounds of thunderstorms or lightning.

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Integration assessment results Once the clinician has completed a comprehensive assessment, the results have to be integrated. Unfortunately, discrepant findings between the multiple informants are all too common. However, these discrepancies can also be very informative and can help the clinician in setting up the treatment plan. For example, when the parents do not report any safety behaviors, but the clinician did identify them during the assessment phase, he or she can integrate this in the treatment plan by planning a short psychoeducation session explaining what safety behaviors are. The clinician will have to use his or her clinical judgment to develop an effective treatment plan. See Table 8.1 for a summary of Lily’s assessment phase.

Treatment plan II: how to do exposure Treatment options For young people suffering from specific phobias, cognitive behavioral treatments (CBT) have the strongest evidence base (Davis & Ollendick, 2005; Ollendick, King, & Chorpita, 2006). These interventions typically include exposure, cognitive restructuring, and psychoeducation with exposure believed to be the most important treatment component (Ale, McCarthy, Rothschild, & Whiteside, 2015). CBT has been successfully delivered to phobic youth using a variety of formats, including spaced weekly sessions (e.g., Cool Kids Program; Rapee et al., in press), intensively (i.e., One Session Treatment; OST; Davis, ¨ st, 2009), and via the internet (Vigerland et al., 2013). To Ollendick, & O date, the majority of controlled trials for phobic youth have evaluated the effectiveness of an intensive CBT approach known as a “One Session Treatment.” This treatment involves a single massed exposure session (maximum 3 hours; Ollendick & Davis, 2012). OST utilizes a range of CBT techniques such as gradual exposure, psychoeducation, ¨ st, cognitive restructuring, and modeling (Ollendick & Davis, 2012; O 1989) and is now considered a well-established treatment for adults, as well as children and adolescents (Davis, May, & Whiting, 2011; Davis & Ollendick, 2005). The main difference with traditional exposure treatment is that during OST the child works through their entire fear hierarchy during one prolonged exposure session. Currently, no studies have directly examined the relative efficacy of spaced weekly CBT in comparison to OST for phobic youth. In contrast to CBT, the evidence for pharmacotherapy agents as either stand-alone treatment or in combination

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TABLE 8.1 Summary of Lily’s assessment phase. Part assessment

Instrument

Outcome

Clinical interview

ADIS-IVC/P

Primary diagnosis: Specific Phobia Animal Subtype (dogs). Child severity rating: 4. Parent severity rating: 6. Clinician severity rating: 5 Additional information: fear is triggered when confronted with most breeds, small and bigger dogs, but more so with bigger dogs, on and off leash, all colors. Active dogs, particularly those that jump, evoke a lot of fear.

Questionnaires

FSSC-R

FSSC-R score Lily: 136

CBCL

FSSC-R score parent: 145 CBCL-score Lily: internalizing (10), externalizing (4) CBCL score parent: internalizing (14), externalizing (7). With the exception of the parent-score for internalizing behavior, all Lily’s scores were in the normal range.

Safety behaviors

Clinician

Lily could not verbalize any safety behaviors, but her parents told the clinician she will hide behind her parents and started wearing a thick winter coat, even when it is warm outside. The parents believe Lily does this in case a dog may bite her.

Functional assessment

Clinician

Catastrophic belief: “If I approach a dog, it will jump up to my face and bite me” Probability rating: 10 Severity rating: 10 Self-efficacy rating: 1

Behavioral assessment

BAT

Percentage of steps completed: 10%; Lily was only able to open the door of the BAT room which had a dog inside in the far corner on a lead (Step 1) SUDs: 7/8

ADIS-IV, Anxiety Disorders Interview Schedule for the DSM-IV; CBCL, Child Behavior Checklist; BAT, Behavioral Assessment Task; SUD, subjective units of distress.

with psychological treatment for phobic youth is limited (Fairbanks et al., 1997; Leonte, Puliafico, Na, & Rynn, 2018). While exposure-based treatments are considered to be the most efficacious for children and adolescents with specific phobias, there remain many misconceptions about exposure which affect clinicians’ use of the technique (Prochaska & Norcross, 1999). For example, practicing clinicians often think that exposure is harmful for the patient and that it will

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increase distress. The latter is true with regard to the start of exposure treatment, when patients usually experience an increase in fear, but the fear will fade after treatment as a result of changing the catastrophic belief (Foa, Zoellner, Feeny, Hembree, & Alverez-Conrad, 2002). However, there are no indications that exposure poses harm to the patient and generally, patients tend to have a positive view on exposure (Deacon & Abramowitz, 2005; McGuire, Wu, Choy, & Piacentini, 2018; Olatunji, Deacon, & Abramowitz, 2009; Richard & Gloster, 2007). Exposure treatment involves prolonged and repeated confrontation with the feared object or situation in a systematic and controlled manner while preventing avoidance (both behavioral and cognitive). Although there usually is a decrease in fear and distress during the course of an exposure session, this is not the goal of exposure treatment, but rather a desirable side effect (Craske & Mystkowksi, 2006; Foa et al., 2002). The goal of exposure treatment is to tackle the catastrophic belief the child or adolescent has by staying in the feared situation for the amount of time that allows the child or adolescent to (1) learn that the catastrophic belief will not happen and (2) to learn that they can tolerate the fear. There are multiple types of exposure: exposure in vivo, imaginal exposure, and interoceptive exposure. An example of exposure in vivo is “live” exposure to the phobic stimulus, such as arranging a dog for Lily. Although exposure in vivo is the most widely used and preferred exposure type, interoceptive exposure can be effective with certain phobias. Integrating elements of interoceptive exposure can be useful when the phobia involves a fear for physical sensations, such as a BII phobia or a specific phobia for heights. For example, interoceptive exposure for BII phobia could be focusing on the disgust the child feels in their body. Exposure in vivo produces greater improvements than imaginal exposure and is typically not a preferred exposure type for younger children as it involves abstract thinking: children may be limited by their developmental capacities and have greater difficulty with imaginal exposures (Davis & Ollendick, 2005). However, imaginal exposure can be a good alternative when the feared object or situation is very impractical to arrange, such as sharks or planes. Another alternative with such situations may be exposure through virtual reality. Some children may have difficulty articulating their belief about the feared situation and this makes developing exposures more challenging for the clinician. In this case, the parents can be a useful guide to assist in determining what the child is fearful of within the situation (see the section on Involving the family). The clinician can also make suggestions to the child, based on what they ascertained from the assessment. For example, “I am wondering whether when you see a dog you worry that it might bite you?” This suggestive questioning may assist in understanding the child’s belief. However, it may sometimes be

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necessary to develop the exposures with limited understanding of the belief. This will mean some greater “trial and error” as the clinician works to ascertain in a gradual way, which aspects of the feared situation create increased arousal for the child.

Exposure treatment: how does it work? The mechanism of exposure treatment for fear and anxiety is thought to be extinction-based (inhibitory) learning (Craske et al., 2008; McGuire & Storch, in press). A fear of a specific object or situation is thought to have its origins in three learning pathways: classical conditioning, vicarious conditioning, and the transmission of negative information (Rachman, 1977). A specific phobia originating from a direct negative experience with an object or situation is thought to be the result of classical conditioning (King, Gullone, & Ollendick, 1998; McGuire et al., 2016). For example, Lily might have had an experience in which a dog bit her. Classical conditioning theory states that because of this experience, Lily has developed an association between the conditioned object (the dog) and the unconditioned stimulus (biting). Because many people with a specific phobia do not report such a prior negative experience, or even prior contact with the object or situation, other learning experiences might play a role (King, ClowesHollins, & Ollendick, 1997; Muris, van Zwol, Huijding, & Mayer, 2010; Ollendick & Muris, 2015). A specific phobia may alternatively originate in the modeling of behavior toward the feared object or situation. For example, Lily may have a friend or parent that has exhibited a fear of dogs. Alternatively, a specific phobia may develop after (repeatedly) receiving negative information about an object or situation. In Lily’s case, her dog phobia might originate from learning about a friend who has been bitten by a dog. When a child continuously experiences the object or situation in absence of the feared outcome (catastrophic belief), as in exposure sessions, the link between the object and the catastrophic belief will fade and extinction takes place (Pavlov, 1927; Urcelay, 2012). However, it must be noted that research indicates that the original response (fear and avoidance) will not entirely fade. Instead, it is thought that exposure creates a new learned response (no/acceptable fear and approach) which will be practiced as the new dominant response; hence, the term “inhibitory learning” (Bouton, Westbrook, Corcoran, & Maren, 2006; Hermans, Craske, Mineka, & Lovibond, 2006).

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Features of a good step ladder A fear hierarchy is the crucial component of a well-thought out and successful exposure treatment protocol. For children and adolescents, a fear hierarchy is often referred to as a step ladder. The step ladder is composed of the steps a child or adolescent is going to take during the exposure session(s) to achieve the goal the clinician and child have decided upon. The step ladder is gradual, meaning that the steps are increasing in difficulty to be able to finally achieve the ultimate goal. A first step to take when creating a step ladder together with the child and parents is to identify a goal that the child wants to achieve by the end of the exposure treatment. By identifying a goal, the clinician and the child have something to work toward and it will help with evaluating the treatment. When Lily was asked about her goal during the treatment planning phase, Lily and her parents agreed that her goal would be to give a big dog a cuddle. The clinician or the family may think that this is too much and that, for example, petting a dog would also be enough of an end goal. However, exposure treatment is thought to be most successful when there is a certain degree of overlearning and when the exposure task is challenging enough that it ¨ st, 1989; Peris gives the child a sense of mastery after its completion (O et al., 2017). Overlearning can be operationalized as taking steps toward the feared object or situation that a person would normally not engage in, in their natural environment. In Lily’s case, this might involve her giving the dog a cuddle, while in her natural environment she might function well enough if she can just walk past a dog. Another example would be a spider crawling over a client’s entire body in the case of a spider phobia. The idea behind overlearning is that this will lead to the greatest violation of the child’s catastrophic ¨ st, 1989). Of course, the end goal should be formulated belief (O together with the child/adolescent and the parents, and all should be on board to work toward this goal. After choosing a goal, the second step into creating a step ladder for the child would be to review the information the clinician has taken away from the assessment phase. Information from the functional and behavioral assessment can now be transformed into a step ladder.1 Together with the child or adolescent, the clinician can start to think about the steps that are necessary to obtain this goal. To identify situations in which the child would encounter the feared object or situation and in which they would be fearful, they can use a worry scale to give all 1 In clinical practice, the functional assessment phase usually already involves creating steps of the step ladder. For clarity purposes, we have separated these two phases in this chapter.

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the identified feared situations a worry/fear rating on a scale from 0 (very relaxed) to 10 (extremely worried/scared). This can help the clinician and child with making a step ladder for the child and decide which steps can be taken first and which ones should be saved until the very end (for an example, see the Cool Kids manual; Rapee et al., 2019). When creating the step ladder, the clinician should keep in mind the characteristics of the feared object or situation that were particularly fear evoking for the child. For example, during the functional assessment, Lily mentioned that she was especially fearful of large, active dogs. The clinician should make sure that this information is incorporated into the step ladder. Importantly, when working with children, the clinician should take the developmental level into account: young children may find it especially hard to think abstractly about how the different steps might make them feel (Holmbeck, Greenley, & Franks, 2004). The clinician can work around the cognitive limitations by concretizing and visualizing the step ladder as much as possible. For example, the clinician may use separate cards on which the child and clinician write down the different situations they identify, after which the child can put them into an order from the least difficult to most difficult (Chorpita, 2007; Davis et al., 2009). See Fig. 8.1 for an example of Lily’s step ladder. When developing exposure steps, clinicians should remember that useful steps are (1) specific, which means that each step is formulated in such a way that it exactly states what the child needs to do, (2) repeatable, which means that the step must entail an activity that the child can repeat multiple times in a week when they are practicing at home, and (3) in the child’s control, which means that the step should entail an activity that the child can do by themselves or with the help of a parent. Also, the steps should be gradual and increasing in difficulty. We recommend determining at least 8 12 steps in the step ladder. After the steps have been chosen, the next step is to choose rewards for reaching the ultimate goal and also for completing the smaller steps. Save a larger reward, such as a big outing with the family or a friend, for achieving the ultimate goal. The child can choose smaller rewards, such as choosing dinner, extra screen time, or special treats or desserts, for achieving each of the steps (Rapee et al., in press).

Fighting fear by facing fear Once the step ladder is created, the next task is to start exposure sessions. Developed at the Centre for Emotional Health, the Cool Kids Program (a program that teaches anxiety management skills to children and adolescentshould be adolescents meeting criteria for a primary anxiety disorder) makes use of a Fighting Fear by Facing Fear form

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FIGURE 8.1 Example of a step ladder for Lily.

(Lyneham, Wignall, & Rapee, in press). This form will help the clinician to both plan and track the steps of the step ladder. The clinician and child fill out the plan at the beginning of each week (depending on the frequency of the sessions) and plan ahead which steps will be carried

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out, when they will be carried out, which coping strategies the child might use (e.g., thinking of realistic thoughts that have been formulated during detective thinking/cognitive restructuring), and what the worry rating is for those steps at the point of filling out the form. During the session, the clinician should repeatedly ask for worry and fear ratings to evaluate whether the child has stayed in the situation for long enough to move on (i.e., to experience a fear drop and learned that the catastrophic belief will not come true). Once the session has been completed, the Fighting Fear by Facing Fear form can be filled out together with the child to evaluate how the session went. The clinician and child can fill out the worry rating during and after the exposure session. Also, they can fill out what the child has learned from the session and the clinician should ask for ratings of the threat expectancies (i.e., probability, severity, self-efficacy). Finally, the child should receive the reward that he/she has picked out. Importantly, in between sessions, the child or adolescent should continue to practice with the steps. The clinician and the child can come up with plans for the homework together and they should discuss how much the child should practice. Depending on the phobic stimulus/situation, the homework can take place naturally (e.g., dogs on the street in the case of a dog phobia) and/or planned (e.g., visiting a dentist in the case of a dentist phobia). In both cases, the clinician should plan the steps to be practiced during the homework carefully with the child and the family to ensure enough practice takes place. As a guideline, the child should practice the planned steps enough to experience a fear drop in the situation and to be able to formulate a learning experience. The clinician and child should evaluate the homework at the beginning of the following session. See Table 8.2 for an example of a Fighting Fear by Facing Fear form completed with Lily for two of the steps in her step ladder.

Tips and recommendations when doing exposure After creating the step ladder, the actual exposure session(s) may seem simple; just follow the steps. However, there are a lot of things to think about when preparing for an exposure session and important things to think about during an exposure session. We have outlined some tips and recommendations below which we adapted from the Cool Kids program (Rapee et al., in press). 1. Be prepared. The clinician should prepare for the session by making sure the feared object or situation is ready and available for the exposure. For example, in Lily’s case, the clinician should make sure a dog is available for Lily’s practice. The clinician should pick a dog

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TABLE 8.2

179

Example for fighting fear by facing fear for Lily.

Planning

Review

What step will I do? When will I do it?

What strategies will I use?

Worry ratings

What did I learn?

What reward did I receive?

Step 1. Look at videos of dogs—Monday

Think of realistic thoughts from detective thinking.

Today: 5

The dogs look friendly

Go for ice cream with dad.

The dog does not pay attention to me and does not come up to me.

Going to the movie theater with mum

During: 3 After: 1

Step 4. Look at a dog through an open window— Tuesday

Think of realistic thoughts from detective thinking. Not wearing my safety jacket.

Today: 7 During: 5 After: 2

that is calm to begin with, then end with a dog that moves around more, but will not bite. If a clinician is uncomfortable or unfamiliar with the feared object or situation, the clinician has to practice confidently handling the object of situation him/herself before starting the exposure session. Furthermore, it is important that the clinician uses calm body language and facial expressions, as even subtle anxious modeling can lead to avoidance of the feared object or situation in the child. If the clinician feels they are not up for it, they should outsource the treatment to a colleague. 2. Be flexible. Situations may evoke more fear than initially thought by the child. Historically, the child has avoided the situation, so the actual situation may be harder or easier than the child originally thought. Another step may need to be added before moving on to the next step if it turns out to be too hard for the child. The clinician should adapt the step ladder where needed. 3. Expect the unexpected. When conducting exposure, the clinician should be prepared for the unexpected with exposure tasks not always going to plan. Exposure for specific phobias often involves the use of animals and is frequently conducted outside of the office in natural surroundings. Hence, there are a number of aspects of the session which are not under the clinician’s control. For example, a dog may suddenly jump up or bark, a spider may crawl into a sweater, or something may fall over in the dark. It is important that the clinician uses these opportunities to model calm behavior and to empathize with the child’s experience. Moreover, the clinician should take these opportunities to reinterpret the event and use it as a learning experience. For example, if a dog jumps on Lily during her exposure

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4.

5.

6.

7.

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session, the clinician could use this opportunity to ask Lily if her feared outcome had come true (e.g., “Let us calm down for a bit and look at what happened. The dog jumped up to you, but did your worst fear come true? You were scared for a moment, but you could handle the fear. Very good!”). Balance the difficulty of the steps. The clinician should make sure that the steps in the step ladder are neither too easy nor too difficult. The child should feel as though each step is somewhat challenging, but not too challenging so that the child can experience a sense of mastery when they have completed a step. Safety behaviors. Although the goal of the exposure for the child is being in the feared situation without engaging in safety behaviors, it is sometimes a good idea to let the child practice the first steps with the safety behavior (Salkovskis, Clark, Hackman, Wells, & Gelder, 1999). The child may be too scared to start with the first steps and by practicing the first steps with safety behaviors, the clinician can motivate the child to be in the feared situation. For example, a child with a specific phobia of the dark may first enter a dark situation with a flashlight. The clinician and child should work toward fading out the safety behaviors over sessions, so that the child learns that the fear fades and the catastrophic belief does not come true despite not using safety behaviors. Vary contexts. As mentioned before, extinction learning is highly context-dependent and it is therefore paramount that the clinician practices exposure in a variety of situations and with varying features of the stimulus (Wolitzky-Taylor, Viar-Paxton, & Olatunji, 2012). For example, Lily should practice with different dog breeds, different sized dogs, and in different situations. Another example, with regards to a specific phobia for elevators, the clinician should practice in different buildings, varying in the number of floors and how old the elevator is. Let the fear drop. The clinician should make sure that the child stays in the situation long enough for the fear to drop and so the child has learned something new (e.g., the dog does not pay attention to me and does not come up to me when I look through the window). Ideally, the fear drops substantially, but as a minimum, the fear should drop at least two points but often this varies depending on the way the child uses the scale. The important thing to remember is that the child should experience a reduction in fear. However, there are instances in which the child stays very fearful and fear ratings do not drop. In this case, the clinician should manage expectations for the child and repeat that although the fear does not drop now, this does not mean that there is no progress and reiterate the child’s achievement (“Although you are still feeling very scared, you are still in

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the situation and your worse fear has not come true, good job!”). The most important focus should always be on discrediting the catastrophic beliefs. 8. Repetition. The key to any successful exposure session is repetition. Each step should be repeated until the child or adolescent feels bored with the step or the anxiety has significantly dropped. The clinician can check this by repeatedly asking for fear/worry ratings. 9. Realistic expectations. Prepare the child or adolescent that there will be good and bad days. The child should know that it is normal that sometimes they might experience more fear in the same situation they could easily face on previous days. Remind the child that it is important to keep on trying.

Maintaining improvement After successful exposure treatment, the child or adolescent has learned that the catastrophic belief is not true, or a lot less believable than they had first thought when starting treatment. As a consequence, the fear has usually subsided and the child or adolescent is able to come into contact with the object and/or be in the situation, without extreme fear and avoidance. Furthermore, the child has learned important skills to handle fear that may arise in the situation or close to the feared object. However, as with all skills, it is important to keep on practicing to be able to maintain the skillset and the results. As mentioned before, extinction learning is highly context-dependent and the original response (fear and avoidance) is still intact, therefore, exposure results are not immune to relapse (Urcelay, 2012). To be able to maintain the desired, new response to the object or situation, it is crucial to generalize the skills and the new response to various contexts by letting the child or adolescent practice at home and in different situations. Even after treatment has ended, for traditional exposure treatment, within the context of CBT or for OST, it is important that the clinician strongly encourages the child/adolescent and their family to continue to expose themselves to the feared object or situation to maintain treatment results. The clinician should make concrete plans with the child during the treatment to make sure that the child has a maintenance plan. It is also advisable that the clinician follows up with the family to ensure they are practicing at home. The same recommendations apply for this maintenance plan as was true for the homework assignments: the steps should be specific, repeatable and under the child’s control. This could include specific daily/weekly tasks. For Lily, this could entail visiting the neighbor’s dog or playing with friends who own a dog (Table 8.3).

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TABLE 8.3 Summary of the steps toward an evidence-based treatment plan. Step

Phase

Component

Step 1

Assessment

Clinical/diagnostic interview (including functional assessment)

Step 2.

Assessment

Additional questionnaires

Step 3.

Assessment

Behavioral assessment

Step 4.

Treatment

Create a fear hierarchy

Step 5.

Treatment

Facing fear by facing fear: exposure session(s) 1 homework

Step 6.

Maintenance

Practicing

Involving the family Involving the parents in the design of stepladders can be important for a successful exposure. This is particularly critical for younger children to help guide appropriate timing and spacing of each step. For the most part, parents will be able to use their extensive knowledge of the child’s anxiety and coping skills to assist the clinician and child to calibrate each step. In some families, this may be more difficult. For instance, some parents may worry that the child will not be able to complete a step and underestimate their child’s ability to cope. In this case, the parent may suggest a step that is too easy for the child and this results in a missed opportunity for tackling a more difficult step. Other parents may want to push their child through the steps too quickly and hence end up increasing the likelihood of failure. As we mentioned earlier, the child should feel as though each step is somewhat challenging but not too challenging so that the child can experience a sense of mastery. It is also important that there is sufficient time within the course of treatment to tackle the most difficult exposures, so if progress is too slow, then it will mean there is less time to tackle the difficult steps. In this instance, the clinician may want to encourage the family to consider a more difficult step than the parent suggests. Parents are less important for guiding the process of developing and executing stepladders for adolescents. Clinicians can use this as an opportunity to encourage more independence in the young person as they develop their own step ladders and take responsibility for managing their own anxiety. However, parents will still be required to ensure that the exposure is feasible within the family’s weekly schedule and can help the young person, if needed, to set up the exposure, making sure the feared stimuli are available and transport is available. For children of all ages, parents may be important for identifying barriers to successful completion of

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the exposure tasks and may be useful to assist the child and the clinician in problem-solving ways to increase the likelihood the exposure tasks will be completed. Ultimately, the child/adolescent needs to be able to execute each step independently from their parents. However, it may be necessary for parents to help support the child in the first instance. For example, a child who is scared of the dark may require the parents to be present when they complete the first few steps (e.g., holding the child’s hand, or standing within close proximity) until the child is ready to complete the step on their own. Parent presence may make the steps easier for the child to complete and increase the likelihood that the step is completed. As mentioned previously, parents can also be important in determining and delivering rewards for the child. In a collaborative process, the parents and child can decide on appropriate rewards for each step.

Tips and tricks One of the most frequent barriers to the successful completion of stepladders is parent anxiety. When a parent has high anxiety, this may not only prevent the appropriate calibration of the steps in the planning phase, but it can also serve as a barrier to executing the steps. Parents with high anxiety may prevent the child from starting the step or may remove the child from the situation too early because of an unrealistic fear that the situation is dangerous. The parent may also communicate unhelpful messages to the child that the situation is scary or that they don’t believe the child is able to complete the step. This could present as a fearful or uncertain facial expression or it could present as more overt statements like “I hope it doesn’t hurt you.” Parents with high anxiety may also provide the child with too much reassurance, like “It’s okay. You will be okay. Nothing bad will happen.” In a recent study in our Center, we showed that when parents were asked to encourage their child to approach an unknown animal, parents of anxious children gave significantly more statements of reassurance than parents of nonanxious children (Anagnos et al., in preparation). These parents were also less likely to encourage the child to approach the animal than parents of children without an anxiety disorder. Another study examining parents’ behavior during children’s medical procedures suggests that reassurance not only communicates to the child that the parent is worried about the situation, but actually serves to increase the child’s distress (McMurtry, Chambers, McGrath, & Asp, 2010). During exposures in which an anxious parent is present, it can beneficial to coach parents about the most appropriate response. For

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example, parents can be encouraged to communicate to the child their confidence in the child’s ability to complete the task. For many parents, this may mean providing a single statement about the child’s ability to complete the task at the beginning of the task and then sitting back (and not rushing in to reduce the child’s distress) and trusting that the child will complete the task on their own. The Cool Kids program focuses on teaching parents the strategies to manage their child’s fears, but these strategies may also be beneficial for parents in managing their own anxiety. The clinician may encourage the parent to develop his/her own gradual exposure hierarchy. This may be particularly useful for parents who experience the same fear as the child and are unable to provide support for their child to complete the exposure tasks. We might encourage the parent to complete a similar stepladder before the child is asked to start their hierarchy, so the parent can be supportive for the child’s task. Having said that, the program is not sufficient to treat parental anxiety disorders and if the parent’s anxiety is impacting on their ability to appropriately support their child during exposure, then parents should be encouraged to seek additional treatment. Another option might be to involve only the nonanxious parent in the treatment program.

Challenging issues While carrying out exposure therapy for specific phobias may appear straightforward, there are a number of challenges that a clinician may need to overcome in order to achieve a successful treatment outcome. Common challenges or pitfalls include children’s lack of motivation, access to phobic stimuli, and difficulties maintaining treatment gains. Phobic children may present with limited motivation to overcome their fear (Oar, Farrell, & Ollendick, 2015). For example, in the case of injection phobia, children may not have the capacity to comprehend the long-term health-related benefits of receiving an injection and thus have low motivation to face their fear. As previously discussed, the use of tangible rewards is critical to reinforce non-anxious behaviors and increase child motivation. Exposure tasks should also be as enjoyable and engaging as possible (e.g., hide and seek with glow sticks for a dark phobic child). With these children, it is important that prior to commencing exposures, the therapist spends sufficient time building rapport with the child and ensuring that the child has a good understanding of the rationale for treatment. A significant challenge for clinicians working with phobic children and adolescents is the sourcing of appropriate stimuli for treatment. For example, when working with an animal phobic child, the clinician must

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seek out a number of different animals to be involved in sessions (e.g., small dogs, large dogs, calm and active dogs, and particular dog breeds). Considerable time also needs to be spent planning where exposure sessions will take place. In relation to animal phobias, if treatment is occurring within the clinic, the animals (e.g., dogs, spiders, snakes, bees, birds) will need to be stored prior to and following the session. They may also require food and water. Additionally, the clinician may need to seek permission from building managers to have animals onsite. Alternatively, if exposure is taking place offsite at a home, park or other public space, the clinician will need to consider who will be present when conducting exposure tasks as well as the child’s safety. For instance, when working with a child who has a lift phobia, the clinician should consider the busiest time of day in the building and/or how to respond if a member of the public approaches the child during an exposure task—particularly if the child has become distressed. It is important to contemplate and mitigate any potential risks when working with children. For instance, if the child has a water phobia, and the clinician is taking them to the beach, they will need to ensure that if the child is able to go into the water that they are swimming in a safe area (e.g., paddling between the lifeguard flags). At times the clinician may need assistance and have to work alongside other members of the public or health professionals to deliver treatment. An example would be when treating an injection phobic child, the clinician may need to work with doctors, dentists, or nurses. Scheduling appointments with the clinician, family, and other busy health professionals is often difficult and is further complicated by the cost associated with having two health professionals involved. Importantly, members of the public and other health professionals often require some form of training/preparation themselves before they are involved in an exposure task. For example, exposure assistants should be taught to avoid reinforcing phobic behaviors (e.g., comforting the child and encouraging them to avoid if they become distressed during the exposure task) and to be aware of verbal threat messages they may give (e.g., “Yes I heard about a pitbull biting a child recently on the news but my dog wouldn’t do that.”). The difficulties faced by clinicians in sourcing suitable stimuli for exposure are also experienced by families. Hence, setting up and carryout home exposure practices requires considerable time and active planning. In our experience, this appears to be one of the greatest barriers to continued exposure practice and consequently maintaining treatment gains in phobic youth. Prior to exposures, the clinician should meet with parents to brainstorm and problem solve as to how they will access stimuli on a regular basis (e.g., contact a local dog obedience school; speak with an airline about going on a standby list for domestic flights).

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Moreover, to enhance compliance with exposure practice, it is recommended that the clinician schedule regular telephone calls or face-toface sessions with the family to address barriers (e.g., lack of time and access to stimuli) to practicing. We have highlighted some of the challenges in working with phobic young people and briefly provided suggestions for how to overcome ¨ st (2012) these. It is recommended that readers see Reuterskiold and O for a comprehensive review of different phobia subtypes and how to tackle specific challenges related to working with these presentations. Despite these challenges, working with phobic children is highly rewarding and interesting. Exposure therapy for these youth is highly effective. However, for it to be successful clinicians need to be organized and creatively design exposure tasks that maximally violate children’s phobic beliefs.

Conclusion Specific phobias are one of the most common anxiety disorders affecting children and adolescents. While children typically experience a range of fears over the course of their development, for a significant proportion of young people these fears persist and cause significant distress and impairment in functioning. Comprehensive phobia assessments include clinical interviews, questionnaires, and behavioral approach tasks with both children and their parents. A thorough assessment provides the foundation for the development of a successful and individualized treatment plan. Exposure-based treatments, delivered either intensively or via spaced, weekly sessions, have been found to be efficacious for phobic youth. When conducting exposure with phobic children and adolescents, it is important that the clinician is prepared and is flexible in their delivery of exposure varying the pace of the session in response to the child’s needs. To ensure treatment gains are maintained, it is important that a maintenance plan is established and that the parents are involved.

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Prochaska, J., & Norcross, J. (1999). Systems of psychotherapy: A transtheoretical analysis (4th ed). Pacific Grove, CA: Brooks/Cole. Rachman, S. (1977). The conditioning theory of fear acquisition: A critical examination. Behavior Research and Therapy, 15, 375 387. Rapee, R.M., Lyneham, H.J., Schniering, C.A., Wuthrich, V., Abbott, M.A., Hudson, J.L., & Wignall, A. (in press). The Cool Kids child and adolescent anxiety program therapist manual. Sydney: Centre for Emotional Health, Macquarie University. ¨ st, L. G. (2012). Real world applications of one-session treatment. Reuterskiold, L., & O ¨ st (Eds.), Intensive one-session treatment of In T. E. Davis, III, T. H. Ollendick, & L. G. O specific phobias (pp. 127 141). New York: Springer. Reynolds, C. R., Kamphaus, R. W., & Vannest, K. J. (2011). Behavior assessment system for children (BASC). In Encyclopedia of clinical neuropsychology (pp. 366 371). New York: Springer. Available from doi:10.1007/978-0-387-79948-3_1524. Richard, D. C. S., & Gloster, A. T. (2007). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In D. C. S. Richard, & D. Lauterbach (Eds.), Comprehensive handbook of the exposure therapies (pp. 409 425). New York: Academic Press. Ryan, S. M., Strege, M. V., Oar, E. L., & Ollendick, T. H. (2017). One session treatment for specific phobias in children: Comorbid anxiety disorders and treatment outcome. Journal of Behavior Therapy and Experimental Psychiatry, 54, 128 134. Available from https://doi.org/10.1016/j.jbtep.2016.07.011. Salkovskis, P. M., Clark, D. M., Hackman, A., Wells, A., & Gelder, M. G. (1999). An experimental investigation of the role of safety behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559 574. Available from https://doi.org/10.1016/S0005-7967(98)00153-3. Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for DSMIV-child and parent versions. London: Oxford University Press. Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 380 411. Available from https://doi.org/10.1207/s15374424jccp3403_2. Silverman, W.K., & Ollendick, T.H. (2008). Child and adolescent anxiety disorders. In: A guide to assessments that work, pp. 181 206. doi: 10.1093/med:psych/ 9780195310641.003.0009. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36(5), 545 566. Available from https://doi.org/10.1016/s0005-7967(98) 00034-5. Urcelay, G. P. (2012). Exposure techniques: The role of extinction learning. Exposure Therapy (pp. 35 63). New York, NY: Springer. ¨ st, L. G., Lindefors, N., . . . Serlachius, Vigerland, S., Thulin, U., Ljo´tsson, B., Svirsky, L., O E. (2013). Internet-delivered CBT for children with specific phobia: A pilot study. Cognitive Behaviour Therapy, 42(4), 303 314. Available from https://doi.org/10.1080/ 16506073.2013.844201. Wolitzky-Taylor, K. B., Viar-Paxton, M. A., & Olatunji, B. O. (2012). Ethical issues when considering exposure, . Intensive one-session treatment of specific phobias (208, p. 195). New York, NY:: Springer.

Further Reading Albano, A. A., & Kendall, P. C. (2002). Cognitive behavioural therapy for children and adolescents with anxiety disorders: Clinical research advances. International Review of Psychiatry, 14(2), 129 134. Available from https://doi.org/10.1080/09540260220132644.

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¨ st, L. G. (1997). Rapid treatment of specific phobias. In G. C. L. Davey (Ed.), Phobias: A O handbook of theory, research, and treatment (pp. 63 80). Chichester: John Wiley. ¨ st, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral O treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy. Available from https://doi.org/10.1016/j. brat.2017.07.008. ¨ st, L. G., Svensson, L., Hellstrom, K., & Lindwall, R. (2001). One-session treatment of speO cific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69(5), 814 824. Waters, A. M., Farrell, L. J., Zimmer-Gembeck, M. J., Milliner, E. L., Tiralongo, E., Donovan, C. L., . . . Ollendick, T. H. (2014). Augmenting one session treatment of children’s specific phobias with attention training towards positive stimuli. Behaviour Research and Therapy, 62, 107 119. Zlomke, K., & Davis, T. E., III (2008). One-session treatment of specific phobias: A detailed description and review of treatment efficacy. Behavior Therapy, 39(3), 207 223. Available from https://doi.org/10.1016/j.beth.2007.07.003.

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C H A P T E R

9 Exposure therapy for children and adolescents with social anxiety disorder Sarah Ryan Radtke, Marlene V. Strege and Thomas H. Ollendick Virginia Polytechnic Institute and State University, Blacksburg, VA, United States

Individuals with social anxiety disorder (SAD) fear negative evaluation by others and avoid social or performance situations in which these evaluations may occur (American Psychiatric Association, 2013). SAD is a common psychiatric condition with a lifetime prevalence of 13% (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), that is multiply determined (Ollendick & Benoit, 2012), and is associated with significant functional impairment across life domains (Aderka et al., 2012). The typical onset is in adolescence (Kessler et al., 2005); however, it has been diagnosed as early as 8 years of age (Beidel & Turner, 1988). SAD often follows a chronic course into adulthood if not treated; thus, early and effective intervention is critical. Empirically supported interventions for this condition typically involve exposure to feared social and/or performance situations. Here, we provide session-by-session guidelines for implementing exposure-based therapy in youth with SAD. To aid in clarification of the exposure-based therapy process, we also provide a case example of this treatment with a 13-year-old socially anxious adolescent. There are a number of social and performance situations that may be considered anxiety producing for youth with SAD. Several commonly feared situations occur at school such as giving presentations, taking

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tests, asking a teacher for help, writing on the board in front of others, and participating in after-school activities. Other commonly feared situations involve informal social interactions such as initiating conversations with peers, attending parties, talking with others over the phone, and dating. Asserting oneself may also cause anxiety including saying no to someone, ordering food in a restaurant, or requesting an item from a store clerk (Albano, 1995; Beidel & Turner, 1988; Hofmann et al., 1999; Ollendick, Benoit, & Grills-Taquechel, 2014; Ollendick & Ingman, 2001). Developmental differences exist regarding the number and types of situations that produce anxiety. For example, adolescents (in comparison to younger children) report more social situations as distressing, and some social situations, understandably, are more relevant concerns for adolescents such as dating (Rao et al., 2007). When exposed to a feared social or performance situation, youth with SAD typically experience an immediate anxiety response, which often includes behavioral avoidance. Initial fear response to a feared stimulus may include physical reactions such as panic-like symptoms, headaches, and stomach aches. Younger children may cry, freeze, cling to a family member, or throw a tantrum in response to a feared situation (American Psychiatric Association, 2013; Beidel, Turner, & Morris, 2000). Avoidance behaviors may be readily apparent, such as avoidance of social interaction or performance opportunities, or they may be more subtle, such as avoiding eye contact or speaking quietly during a conversation. These avoidance behaviors, if regularly repeated, strengthen the associated fears and increase the likelihood of continued avoidance. Exposures involve the therapeutic interruption of this cycle, with repeated approach to feared stimuli (Young, Ollendick, & Whiteside, 2014). Briefly, the therapeutic effect of exposures can be understood through different theoretical models grounded in behavioral and cognitive learning principles. As noted in earlier chapters, two primary theories have been put forth: habituation and inhibitory learning. Theoretical differences between the habituation and inhibitory learning models are reflected in their differing approaches to exposure-based therapy (see Himle, 2015; McGuire & Storch, 2019 for reviews). However, since both approaches are empirically supported and based on extinction learning, we put forth an exposure-based therapy protocol that combines the two by drawing procedures from both and discussing the various ways in which the clinician can flexibly choose from both models to enhance treatment outcomes. For example, in our discussion of continued exposure practices (see Sessions 5 11), after initial low-level anxiety-producing exposures are successfully accomplished, selection of further exposure activities is a collaborative effort between client and therapist and whether the exposures proceed

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gradually (i.e., habituation approach) or variably (i.e., inhibitory learning approach) is not critical.

Introduction to therapy structure In the following sections, we present session-by-session guidelines for implementing exposure therapy for SAD in practice. Sessions 1 4 are dedicated to psychoeducation and skill building, whereas Sessions 5 11 are focused upon exposure practice. The information and skills gained during the first four sessions provide an important foundation for the successful completion of the exposure activities. The final session (12) is dedicated to reviewing material learned during treatment and discussing maintenance of treatment gains. Although a standard, 50-minute therapy session is sufficient to complete the goals of each session, the session length is flexible. Possible reasons for adjustment of the session duration include the client’s age, cognitive abilities, attention span, severity of anxiety symptoms, engagement with the session content, and practice of the skills between sessions. While seven sessions are dedicated to exposure practice per our model, the precise number that is needed for each client will vary. The number of sessions can be increased or reduced depending on what is necessary to accomplish treatment goals as determined in Session 2. Of course, flexibility is crucial, not only in the length and number of sessions but also in the manner in which the material is presented to the family. The client’s parents are invited to be actively engaged throughout treatment. They are described as “teammates” on the client’s treatment “team.” Their participation is especially important during Session 1 and the goal-setting portion of Session 2. Additionally, for the majority of children and adolescents, parents can provide reminders regarding assigned treatment homework activities or assistance completing them. This is particularly necessary for at-home exposure activities that may pose logistical challenges (e.g., transportation). Parent participation in each individual session is flexible and clinical judgment should be used to determine what is most appropriate for each client. For children and younger adolescents, parents can serve as additional models of the skills being learned, characters in role-plays, and encouragement of participation; older adolescents, on the other hand, generally value the independence of meeting with the therapist without their parents present. When parents are not actively participating in each session, we recommend that they are present for at least a few minutes at the end of the session to review the covered material, discuss the planned homework activity and how they can assist, and to allow the therapist to answer

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any questions they may have. For further discussion of parental involvement, see section below titled “Potential treatment challenges.” Because SAD is typically characterized by adolescent onset, and prevalence rates are lower during childhood, throughout the session summaries given subsequently, we refer to youth as “adolescents.” Additionally, to increase readability, the pronoun “he” will be used to refer to the client and the pronoun “she” will be used to refer to the therapist rather than “he/she.”

Introduction to case example James is a 13-year-old Caucasian male who lives with his biological parents and his 15-year-old sister. According to both James and his parents, he experiences significant anxiety in both social interaction and performance situations. Situations at school—including participating in class, giving oral presentations, walking in the hallways, asking his teachers for help, and eating in the cafeteria—are particularly difficult for him. Although James does not refuse to attend school, his anxiety interferes with his academic performance and causes him significant distress. James reports that he has four close friends that he has known since elementary school, but explains that he has trouble making new friends because he is uncomfortable initiating conversations and talking to new people. James indicated that he wishes he could join his school’s robotics club or try out for the eighth-grade lacrosse team, but he does not currently participate in any extracurricular activities because of his social anxiety. James’ parents shared that they become frustrated when James does not speak up when addressed by their friends and extended family members and that he will not go into shops or restaurants alone. Otherwise, they noted that his anxiety does not significantly interfere in other aspects of their family’s life, although they reportedly worry about his academic performance and wish that he could feel more confident.

Session 1: building rapport, psychoeducation, orientation to treatment Session 1: Objectives—Build rapport with the family, particularly the adolescent; provide psychoeducation about anxiety and normalize it; introduce the treatment approach The first session begins with a rapport-building activity, which facilitates the adolescent’s comfort in the therapy session and allows the therapist to get to know the adolescent. Because it may be particularly difficult for a socially anxious youth to talk about anxiety, we

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frequently begin the session talking about something more neutral and less anxiety producing such as hobbies and interests. Following about 10 15 minutes of rapport building, the therapist transitions the conversation to the topic of anxiety, discussing why we experience anxiety and normalizing the client’s experience. The therapist also introduces the three-component model of anxiety and the concept of the connection between our thoughts, our feelings (both emotional and somatic), and our behaviors. Relevant examples are provided and it may be helpful to have a visual representation of these relationships as well. Initially, rather than focusing on the adolescent’s experiences, it is recommended that examples be provided in the abstract or by the therapist referring to herself or hypothetical clients. This strategy removes the demand for self-disclosure at this point in treatment. Additionally, the use of personal examples or examples from other adolescent clients can further normalize the adolescent’s experience. If the client is struggling to understand the model and would benefit from a more concrete example, most children and adolescents can easily grasp the concepts when they are applied to fears of dogs or some other specific phobia. The last goal of the session is to describe the treatment plan to the family. They are informed of the anticipated schedule of treatment (i.e., approximate length of sessions and number of sessions) and given a brief summary of the plan for the two parts of treatment (i.e., Part 1— Building skills related to recognizing emotions, reducing anxiety, and interacting in social situations—Sessions 1 4; Part 2 Practicing these skills in situations that trigger the client’s anxiety—Sessions 5 11). The therapist also provides rationale for the use of exposure therapy. It is important to emphasize to the family that while the adolescent’s anxiety may decrease over the course of the exposure activities, it does not have to decrease for treatment to be successful (combing the habituation and inhibitory approaches). With most families, it is also helpful to process and normalize any anxiety the adolescent or parent may be experiencing regarding the future exposure activities. Lastly, at some point during the first session, the therapist shares with the client and his parents that therapy homework tasks will be assigned at the end of each session and reviewed at the beginning of the next session. It should be emphasized that the homework will not be graded or evaluated, but that homework completion is important for the client’s success in treatment. At the end of the current session, the client is asked to identify two neutral or positive situations that happened to him over the course of the week and write down the thoughts, feelings, and behaviors that occur in those situations. Although it is not always necessary to begin with neutral or positive situations rather than anxiety-provoking situations, at this point many clients find attending

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to and discussing anxiety-provoking experiences difficult. Beginning with neutral/positive situations generally allows the first homework assignment to be less aversive for the client.

Case example James attends the session with his mother. The therapist begins the session by inquiring about the family’s recent summer vacation and then transitioning the conversation to James’ hobbies. He is initially reticent, but warms up and becomes more talkative as the conversation progresses. He discusses his interests in science and computers and his enjoyment of Legos, lacrosse, and video games. After about 10 minutes, James appears more comfortable, and the therapist introduces the topic of anxiety. The therapist discusses how we all experience fear or anxiety at some point and that they are normal biological and psychological responses. James and his mother brainstorm situations in which it would be problematic if a person did not experience ANY fear or anxiety (e.g., before a final exam, when confronted by an angry dog, walking alone in a city at night) and the group discusses how mild fear or anxiety can actually be helpful in some situations. The therapist draws a triangle on the whiteboard in the treatment room and writes “thoughts,” “physical feelings,” and “behaviors” on the three corners. When asked how his body feels when he is anxious, James shares that his stomach hurts and he gets sweaty and that sometimes he shakes. The therapist normalizes James’ experience of these physical sensations and shares an example of a hypothetical teenage girl who feels very anxious answering questions in class. She writes down examples of all three parts of the triangle. When the therapist writes under “behaviors” that the student in the example never volunteers to answer questions and will avoid making eye contact with her teacher so she is not called on, James shares that he also does not volunteer to answer questions in class and that he asks his teachers if he can do other assignments rather than oral presentations. This provides an easy transition into a discussion of the way that avoidance reinforces anxiety and the presentation of the treatment rationale. The therapist emphasizes that avoidance of anxiety-provoking situations is a very common coping strategy. However, while avoidance reduces anxiety in the short term, it reinforces anxiety in the long run. She notes that when anxiety-provoking situations are avoided the individual never learns that the scary things they believe will happen do not actually occur or that they can manage their anxiety without leaving the situation. She returns to the example discussed earlier to highlight these concepts and James and his mother express understanding.

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The therapist shares that in a few weeks she will help James practice being in situations that are difficult for him so that he can practice navigating the situations, become more comfortable in them, and challenge his anxious thoughts. James instantly appears more uncomfortable so the therapist reassures him that before they begin those exposure activities, they will spend a couple of weeks planning for them and practicing new skills, so he can successfully accomplish them. Lastly, the therapist notes that she will be meeting with James for 1 hour per week over the next couple of months. She also emphasizes that the process will be a “team effort” between James, herself, and James’ parents and that they will all be working together to help address his anxiety. To conclude the session, the therapist tells James that she will be asking him to complete tasks and activities at home so that he can practice what he is learning in therapy. He nods and responds, “Just like homework to practice what we learn in school. Makes sense.” The therapist asks him to record two positive or neutral situations that occur over the next week and the specific thoughts, feelings, and behaviors that accompany them. James’ mother adds that if he has trouble remembering his therapy homework it could be added to the family’s weekend chore chart.

Session 2: review of the three-component model of anxiety, goal setting, and constructing an anxiety/avoidance hierarchy Session 2: Objectives—Reinforce psychoeducation principles; identify anxiety-provoking situations; create an exposure hierarchy to be used during treatment Beginning with Session 2, the therapist begins all sessions by reviewing the client’s homework assignment from the previous session. If the assignment was not completed the therapist and client complete it together before proceeding with the session. The first portion of Session 2 is dedicated to reviewing the three-component model of anxiety that was introduced in Session 1 and reviewed in the homework assignment. Additional examples of positive situations can be practiced, but the goal is to practice with negative/anxiety-provoking situations as well, particularly situations that are relevant to the client. The therapist can ask the adolescent to share a situation over the past week that was difficult for him, and that situation can be processed using the model. The therapist has sample situations and hypothetical scenarios planned ahead of time in case the adolescent does not identify any or more practice is needed. For homework, the therapist asks the adolescent to again record the thoughts, feelings, and behaviors that occur in two situations, but this time specifies that the situations should be anxiety-provoking.

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At least half of the session is dedicated to discussing the specific situations which are anxiety-provoking for the adolescent, identifying two to three specific goals that he is willing to work toward, and constructing an exposure hierarchy. If information regarding the client’s anxiety was gathered during any pretreatment assessment, it can be incorporated and used to facilitate the conversation. Although some clients and their parents can easily name multiple treatment goals, other families have difficulty doing so. In that situation, helpful questions to ask include: In what ways does anxiety mess things up in your life? How would your life be different without anxiety? At home? At school? In public? If you could snap your fingers and instantly feel confident in three different situations what would they be? After goals are identified, the therapist may need to help the family modify them slightly. It is important that the identified goals are specific, measurable, and feasible. For example, in general, the following three goals are specific, measurable, and could be attainable over the course of treatment: “eat lunch in the school cafeteria every day for one week,” “text crush and ask him/her to a movie,” “ask three businesses for summer job applications.” The family is told that they will know that adolescent is ready to graduate from therapy when his goals have been accomplished or he and the therapist are confident that he can accomplish them independently in the near future. Parent contribution to this conversation is encouraged and welcomed. However, it is important to emphasize that although you would like to hear from the adolescent’s parents as well, the client’s perspective is very important. Everyone sees situations differently and to best help the client we need to know how he feels in various situations and what he thinks about them. Sharing this can be used to encourage more reticent adolescents to participate and to encourage parents who tend to overwhelm the conversation to allow their child to speak first. After goals are agreed upon, the group can work together to construct an exposure hierarchy. The hierarchy includes tasks that the adolescent identifies as easy, moderately difficult, and difficult. The hierarchy includes situations/activities that the client has already identified are challenging for him, but also includes tasks that can build toward his overall treatment goals. For example, if a client’s primary goal was to perform in a music recital, exposure activities on his hierarchy could include doing a “recital” for family members, showing his friends a video of himself playing at home, doing a “recital” for his friends, and giving a presentation at school (to practice being in front of a group of people). These types of “subgoals” may not be exposure tasks that are initially suggested by the adolescent or his parents, but in addition to serving as exposure activities more broadly, they can be especially helpful in moving the client toward his treatment goals.

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Case example James comes to the session having completed his homework assignment. He shows the therapist that he wrote about being invited to go swimming in his best friend’s new pool and beating a hard level on his favorite video game. The therapist reviews the thoughts, feelings, and behaviors that James wrote about and praises his good work. James’ mother praises him as well and notes that he did it without needing a reminder. The therapist tells James that she would like them to spend a few minutes practicing using the three-component model just like he did for homework. When asked to share a situation that occurred over the last week that caused him anxiety, James thinks for a couple of seconds and quickly says that he cannot think of any situations. James’ mom says, “What about what happened with your homework last night?” That prompts James to share, “Oh yeah. . . I had forgotten what problems we were supposed to do for math homework and Mom and Dad kept insisting that I text a guy in my class to ask but I didn’t want to.” The therapist praises James for sharing, and the group processes the situation and James’ thoughts, feelings, and behaviors. The therapist then suggests two hypothetical scenarios (a student whose teacher pulls her aside as she enters the classroom and says that he needs to see her after class; and a soccer player being asked to take the potentially gamewinning penalty shot) and the group applies the three-component model to both. Notably, James comments, “The thoughts I would have if I had to take the penalty shot would probably be really different from what Rai [his best friend] would think since he loves soccer and has been playing his whole life.” The therapist tells James that he is probably right and that at their next session they will discuss how changing one’s thoughts can change how they feel and behave. The therapist asks James to write about his thoughts, feelings, and behaviors in two anxiety-provoking situations that happen to him over the next week. The therapist then tells James and his mother that she would like to discuss their goals for treatment. Because she completed a semistructured interview with James and his parents before beginning treatment, the therapist already has a good sense of the types of social situations that cause James to feel anxious. She asks James to list some of these on the whiteboard and to circle the situations in which he would most like to feel more comfortable. The group then brainstorms possible goals for treatment. James lists “doing an oral presentation and getting a good grade on it,” “playing on a lacrosse team,” and “not being so quiet at school.” His mother agrees that those are good ideas and also suggests “being able to go into a store alone” and “being willing to introduce himself to new people.” The therapist discusses all of these suggestions with James and his mother and helps them narrow the list to three specific

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and measurable goals. The final agreed upon goals include “try out for the 8th grade lacrosse team,” “volunteer to answer a question in class at least once per day for a whole week,” and “go into McDonalds alone, order and pay for a McFlurry.” The final activity for the session is creating James’ exposure hierarchy. With the assistance of the therapist and some suggestions from his mother, James easily fills in his hierarchy using situations he wrote on the board earlier and steps toward his goals.

Session 3: cognitive restructuring Session 3: Objectives—Identify anxious self-talk; labeling distortions; challenging thoughts After reviewing the client’s homework assignment, the therapist indicates that during the current session they will be focusing on how one component of the three-component model, our thoughts, influences both our behaviors and how we feel (both emotionally and physically). Vignettes, cartoons, or screenshots from television shows or movies can be used to illustrate how a character’s behaviors and emotions may differ depending on whether they are thinking negative thoughts or “coping thoughts” (i.e., thoughts that are both realistic and promote resilience). It can also be helpful to return to the scenarios that were discussed in Sessions 1 and 2 and discuss how different thoughts could result in different feelings and behaviors in those situations. When the client understands this relationship, the therapist introduces “thinking traps” (i.e., cognitive distortions): patterns of thought that are negatively biased and reliably contribute to feelings of anxiety. The therapist discusses how everyone is susceptible to these traps at times but that when we consistently think in those ways our thoughts can begin to interfere in our lives. Some of the most common distortions that are present in adolescents with social anxiety are listed subsequently. However, there are others that you may wish to review with your client based on their relevance. • Filtering—Focusing solely on the negative and ignoring all of the positive • Catastrophizing—Assuming the worst-case scenario, magnifying the negative and minimizing the positive • Jumping to conclusions—Being convinced of something with little evidence to support it • Mind reading (a form of jumping to conclusions that is particularly relevant to social anxiety)—assuming you know what another person is thinking

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• Overgeneralization—assuming all experiences and people are the same, based on one negative experience • Shoulds/musts/oughts—holding tight to personal rules on how people ought to behave, how someone should feel, or how an interaction should unfold. It can be helpful to provide the client with a worksheet which defines these distortions. He then completes an activity that allows him to practice labeling these thinking traps. Clients also benefit from coming up with thoughts, hypothetical or personal, which fit into each thinking trap category. However, initially most clients find it easier to label thoughts that have already been generated and thus having example thoughts planned is recommended. After he has practiced matching the various types of thinking traps with specific thoughts, the client is instructed that the next step is practicing challenging those thoughts and identifying coping thoughts. Using an analogy of a detective or lawyer is often useful for illustrating how the client should look for evidence for and against his thoughts. Some clients also benefit from asking questions such as “Is this a thinking trap?,” “What else could happen in this situation other than what I first thought?,” or “What would I say to a friend who told me she was thinking this way?” It is helpful to provide worksheets for the client on which the specific thought can be written across the top and the evidence for and against the thought can be written in two columns. After the adolescent has challenged a few practice thoughts, he is informed that the last step involves identifying coping thoughts that a person can think instead. For example, if the client has identified the evidence for and against the thought “If I try to present in front of the class I will stumble over my words and sound dumb,” a possible coping thought is “I know the material well and if I do stumble I can just pause for a second and then keep going.” When identifying coping thoughts, some adolescents find it helpful to imagine how a hero, mentor, or role model might think about a situation. The therapist also informs the client that although coping thoughts are often relevant to specific situations, they can be general too. For example, “I am brave and staying in situations that make me anxious will make me stronger” or “If other kids laugh at me they are just being rude and I can ignore them.” The therapist encourages the client to write down a few coping thoughts that are relevant to his daily life and review them daily. For homework, the adolescent is asked to record his thoughts in two different anxiety-provoking situations, write down the evidence for and against the thoughts, and identify at least one coping thought for each situation.

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Case example When reviewing James’ homework assignment, he admits that he only remembered to write about one situation so the therapist has him identify a second, and they apply the three-component model to it. The therapist reminds James of what he had said in the last session about how his thoughts and Rai’s thoughts would likely be different, even if they were both in the same situation (i.e., shooting a penalty kick in a soccer game). They discuss how Rai (James’ best friend) would feel and behave in the situation and how that would differ from James. The therapist then tells James that the same person can also feel and behave differently in the same situation depending on what they are thinking. She decides to introduce the concept of “coping thoughts” at this point, because what James listed as what Rai would think were good examples of coping thoughts. Because James has previously shared that he enjoys Marvel movies, the therapist shows James a screenshot from a Marvel film and has him draw a thought bubble above each characters’ head and fill in thoughts they may be thinking. James and the therapist discuss how those specific thoughts will influence how each character feels and behaves in the situation. James is then presented with a duplicate of the same screenshot and is asked to identify a thought for each character that is the opposite of what he wrote the first time (i.e., a character whose thought had a negative or anxious thought is given a coping thought and vice versa). They then discuss how the characters will feel and behave now that they are thinking their new thoughts and the therapist highlights that thinking coping thoughts allows the characters to feel more confident and behave in a way that helps them reach their goals. The therapist and James review a worksheet that lists various thinking traps and James has no trouble completing a worksheet that asks him to label which thinking traps correspond to specific thoughts. James also labels the thinking traps that apply to the Marvel characters and then James and the therapist use the whiteboard to record the evidence for and against two of the characters thoughts. James doesn’t appear particularly interested in the detective or lawyer analogies, but nonetheless is very successful at identifying the evidence for the two thoughts. They then return to the two situations James wrote on his homework sheet, challenged the thoughts he had written down, and identified coping thoughts that were appropriate for each situation. James’ mom joins the session for the last few minutes. James shares with her what had been discussed, and the therapist assigned his homework activity for the week.

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Session 4: social skills and assertiveness training Session 4: objectives—identify social skill deficits; introduce strategies for improving social skills Although not all individuals with SAD exhibit social skills weaknesses, a good proportion do. Socially anxious youth may avoid eye contact, speak quietly, interrupt, maintain a blank expression, or not ask questions. Being assertive often is anxiety-producing, thus they may have skill deficits in this area as well. The goal of Session 4 is to help the adolescent identify any social skill weaknesses and identify strategies for practicing skills. There is considerable flexibility within this session: some adolescents may not have any social skills weaknesses or difficulties being appropriately assertive and the session can be skipped entirely, some adolescents may benefit from a single session addressing a small number of easily targetable skill weaknesses, and others may require a couple more sessions in order to sufficiently discuss and practice each social skill deficit. After homework review, the therapist, client, and his parent(s) discuss social skills and work to identify any weaknesses the client experiences. Some youth will be hesitant to label their weaknesses and may feel criticized if others (e.g., the therapist, parents) label them directly. The therapist should be prepared to assist the adolescent with identifying his weaknesses in a manner that does not provoke defensiveness. Asking “What behaviors do others do that get in the way of successful social interactions?” can begin the discussion without immediately commenting on the adolescent’s behaviors. Additionally, for older adolescents and those who prefer to work independently with the therapist, initially introducing this topic with the adolescent alone can sometimes facilitate a more open discussion. Although many adolescents can identify appropriate social skills and discuss when they are important to implement, some clients will need more explicit instruction on what behaviors they should be exhibiting. Once it is clear that the adolescent understands what the appropriate behavior is and how that contrasts with how he typically acts, he is encouraged to practice the appropriate behaviors until he feels comfortable exhibiting them in various situations. During the session, social skills can be practiced during role-plays with the therapist. Some clients also benefit from watching videos of common social interactions and identifying the appropriate and inappropriate social skills that are exhibited by the characters. These videos can also offer the adolescent practice with perspective taking, and he can be asked to consider how a specific character may feel when another character exhibits certain behaviors (e.g., how person A might feel when person B does not make eye

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contact or ask follow-up questions). Outside of the session, social skills can be practiced alone (i.e., imaginally or in front of a mirror), with a friend or family member with whom they feel comfortable, or in a reallife situation. Most adolescents benefit from progressing through each of these types of situations. Furthermore, some clients benefit greatly from viewing video recordings of their own behaviors in social situations in order to monitor progress in their targeted social skills. Additional social skills training resources for clinicians and families include: • http://www.modelmekids.com/aspergers-friend.html • http://www.skillstreaming.com • Bierman, K. L., Greenberg, M. T., Coie, J. D., Dodge, K. A., McMahon, R. J., & Lochman, J. E. (2017). Social and Emotional Skill Training for Children: The Fast Track Friendship Group Manual. • Laugeson, E. (2013). The Science of Making Friends: Helping Socially Challenged Teens and Young Adults (w/DVD). • Matson, J. L., & Ollendick, T. H. (1988). Psychology Practitioner Guidebooks. Enhancing Children’s Social Skills: Assessment and Training. • Toole, J. (2016). How to Talk with Friends: A Step-by-Step Social Skills Curriculum for Children with Autism. Homework activities are planned which facilitate practice of the adolescent’s specific social skill weaknesses. Before ending the session, the adolescent is informed that beginning in the next session he will begin practicing all of the skills he has learned in social situations, so he can further improve his skills and begin to become more comfortable in these types of situations.

Case example James proudly shows the therapist that he completed all of this homework assignment this week. He had recorded two anxietyprovoking situations, his primary thoughts in those situations, the evidence for and against those thoughts, and new coping thoughts that could replace his anxious thoughts. Based on her observations of James, the therapist noticed he exhibited at least minor social skill weaknesses. The therapist initiates the topic by stating, “There are certain rules dictating how we should behave during social interactions. They apply to both how and what we talk about as well as our nonverbal behaviors like how frequently we make eye contact with the person talking and how close we should stand to someone. When we follow those rules and behave how others

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would expect us to, they tend to respond favorably to us. However, when we do or say things that don’t follow the rules or are unexpected, the people we’re around may enjoy interacting with us less. Does that make sense?” James responds, “Yeah, it does. This one girl in my grade always talks super loud and she never gives anyone else a turn to talk, so people don’t seem to like to hang out with her.” The therapist emphasizes that that is a great example of what she is talking about, and both she and James’ mother share examples of people they have interacted with social skills deficits, including how being around those people makes them feel. When asked if he thinks he ever behaves in a way that might interfere in his social interactions James states, “Well I guess I’m kind of the opposite of that girl I mentioned; I usually talk pretty quietly and people tell me they can’t hear me sometimes. And even though I’m good at letting people talk sometimes I think I should ask them more questions to keep the conversation going. I just worry they’ll think my questions are dumb.” The therapist praised James for acknowledging those weaknesses, and his mother asks if he’d be okay with her noting a behavior that she had seen. He indicated that that was fine, and she shared that she has noticed that he seems restless and fidgets a lot when he is talking to people. James says “I guess that’s true. I never thought that that would bother anyone though.” The therapist and James role-play a conversation during which the therapist is very active and fidgets throughout. Afterward, she asks James how her fidgeting made him feel. He responds, “I definitely see your point. It made me feel like you were really uncomfortable and didn’t want to be talking to me. I guess that is something else I should work on.” The group discusses how James can practice speaking at an appropriate volume, asking questions, and not fidgeting with family members and friends he is comfortable with and eventually with people he is less comfortable with. They do two practice conversations in the session with the therapist and James’ mother pretending to be two of his classmates at school. For homework, James agrees that he will have another practice conversation with his mother at home, and then will practice once with his best friends and once with a peer in his youth group meeting this Sunday.

Sessions 5: first exposure practice Session 5: objectives—complete initial exposure(s) in session; prepare for exposure homework Beginning with Session 5, treatment shifts to exposure practice in anxiety-provoking situations. (Although some of the activities

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completed in Sessions 1 through 4 might also have been anxietyproducing.) Although these practice activities are often referred to as “exposure activities” or “exposures,” for younger children, “practice activities” or “challenges” are more appropriate terms. The precise term used is less important, regardless of the client’s age, provided that they understand that the goal is to practice the skills they have been learning in situations that elicit anxiety. Comparing social anxiety treatment to athletics, music, acting, or any other learned skill can illustrate that, after an individual learns about a skill, they need to practice the skill in real life to see gains and improvement. If needed, a review of the psychoeducation about exposure therapy from Session 1 should be provided. Together with the client’s parent(s), the therapist and adolescent review the exposure hierarchy that was created in Session 2 and make adjustments if needed. A low-level exposure activity is selected to practice in this session. The therapist helps the adolescent prepare for the exposure by processing any anxious thoughts he is having and encouraging him to challenge those thoughts and identify coping thoughts. It is also beneficial to review the various social skills the client has been practicing and discuss how those skills will be utilized during the exposure. Subjective units of distress (SUDs) ratings can be provided by the adolescent before, throughout, and after the exposure. These ratings can be used to illustrate any reductions in anxiety occurring across and between exposures. However, some clients have difficulty accurately rating their SUDs or become frustrated being asked repeatedly. In these instances, it is not essential to collect SUDs ratings. Instead, adolescents can qualitatively report their anxiety level and their accomplishment of social tasks can be emphasized more than the reduction, or lack thereof, in anxiety (e.g., regardless of whether his anxiety reduced, he successfully introduced himself to a stranger, ordered food at a restaurant, spoke on the phone, etc.). For clients who do engage with and benefit from rating their SUDs throughout exposures, a simpler 1 10 scale is recommended instead of the typical 1 100 scale used with adults. After completing the exposure activity, the therapist debriefs with the adolescent. The adolescent is asked to describe what happened during the exposure and how they felt. Special attention is paid to the anxious thoughts he identified before the exposure and any that occurred during the exposure, including what labels (Session 3) he would give those thoughts. Socratic questioning is used to elicit whether his feared outcomes occurred and whether anxious thoughts about himself, others, or the situation were accurate. The therapist and client also process whether the goals of the exposure were accomplished. As noted above, the goals of the exposure should pertain to concrete, measurable

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behaviors (e.g., maintaining a conversation for five minutes) instead of abstract (e.g., talking well) or emotion-based goals (e.g., not feeling anxiety), or goals the adolescent does not have direct control over (e.g., the other person will laugh at my joke). The therapist should praise the adolescent for any efforts toward his goals, and discuss with the adolescent any obstacles he encountered when working toward his goals and how he dealt with these obstacles. The therapist and adolescent may wish to discuss future strategies for addressing similar obstacles that may occur during his exposure homework. If there is time the exposure can be repeated or a second exposure can be conducted following the same process as the first. As always, the therapist ends the session by discussing the homework assignment. The importance of regular exposure practice outside of the session is emphasized, and a well-defined plan is made for the coming week. Parents are important facilitators of exposures activities outside of the session, and the parents’ role of the next week is defined as well. Adolescents are also encouraged to implement the skills they have learned in treatment in any anxiety-provoking situations that occur in real life, even outside of the planned exposure activities.

Case example James describes the practice conversations he engaged in and proudly tells the therapist that he practiced with two peers at his church’s youth group instead of just one. His mom comments that he exhibited very good social skills with her and James responds, “Well it was pretty easy practicing what we talked about with you since I’m so used to talking to you. But when I spoke to the guys at church I made sure I asked questions and spoke up, and we had really good conversations! Maybe practicing the social skills will make situations like that always go better. . .” The therapist praised James for his practice and encouraged him to keep it up. She noted that using good skills will not “always” make social situations go smoothly but will increase the likelihood that they will. The therapist reminds James that today they will be beginning the phase of treatment where he is practicing implementing all of the skills he has learned in various anxiety-provoking situations. She uses the sports skill analogy and tells James, “I know you like lacrosse so I am going to compare getting good at playing lacrosse to being good at being in social situations. A person could learn all of the rules of lacrosse, read books about all of the fundamental skills and how to build them, watch videos of players demonstrating those skills, and go to games to watch good players, but he or she won’t ever really get any

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better at playing lacrosse until they pick up a stick and start practicing. But, on the other hand, if they just started practicing and never learned any of the rules and didn’t know anything about the important skills, they wouldn’t even know how to practice correctly. What we are doing here in treatment is similar. You have learned a lot about how to manage your anxiety and how to act in social situations, and that was really important, but now you have to practice those skills in real-life situations so you can get more and more comfortable in the situations.” The therapist takes a copy of James exposure hierarchy out of his chart and reviews it with James and his mother. They agree that it looks good, and there is nothing either of them thinks should be added. The therapist asks James to pick an exposure activity to practice during the session, and he picks “maintaining a conversation with an adult” (which he finds easier than with a peer and easier than initiating a conversation). When asked what he is thinking about the exposure James shares, “Well I’m worried I won’t have anything to say, or that I’ll stumble over my words while talking, and that they will think I’m stupid.” He and the therapist discuss the evidence for and against those thoughts and James comes up with the coping thoughts, “If I run out of things to say I can comment on how hot it is today and ask if they’ve ever been to the beach I’m going to with my family next week” and “Everyone stumbles on their words sometimes. If I do, I can just repeat myself and the person probably won’t think anything negative about me because of it.” The therapist also reminds James of the social skills he has been working on and they discuss what it would look like for him to use those skills appropriately during the exposure. When James indicates he is ready for the activity, the therapist invites her secretary to enter the therapy room and to initiate a conversation with James. The pair converses for approximately 3 minutes and then the therapist processes the exposure with James. He excitedly comments, “I didn’t even need the conversation prompts I came up with!” They discuss the anxious thoughts he had before the conversation, she inquires whether any new anxious thoughts occurred during the conversation, and she praises him for his overall completion of the activity. Additionally, the therapist praises James for not speaking quietly and for asking one question. She encourages him to ask another question during the next conversation. James repeats the exposure with the same person a second time, conversing for 6 minutes, and again processing the experience with the therapist afterward. He notes, “I thought that would be harder since you said we’d talk for longer, but I actually felt less anxious than the first time.” For his homework, James is asked to practicing maintaining a conversation with three different people. James’ mom shares that his father’s company is having their annual summer picnic over the weekend, so

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there will likely be many opportunities for James to converse with people who start a conversation with him.

Sessions 6 11: continued exposure practice Session 6 11: objectives—continue with exposures from the exposure hierarchy Each of the remaining sessions begins by reviewing the exposure tasks the adolescent was assigned for homework. Completion of the tasks is thoroughly praised and incompletion is processed. Barriers to the completion of the exposures are discussed both with the client and his parent(s), and steps to ensure the completion of the activities the next week are planned. As noted in Session 5, adolescents are encouraged to implement the skills they have learned in treatment in any anxiety-provoking situations that occur in real life. To encourage this behavior, the therapist regularly inquires whether the adolescent practiced his skills in any situations outside of the planned exposures. The remaining treatment sessions focus on gradually increasing the difficulty of the exposure activities. Once the client has experienced success with a few initial exposures, the selection of the exposure tasks at each session should be collaborative between the client and the therapist, regardless of the chosen task’s difficulty. Although some clients do prefer to proceed up their exposure hierarchy in order, others prefer to skip around and practice exposures which are directly related to their immediate goals. For example, a client with an upcoming oral presentation at school that cannot be avoided might choose to practice exposures related to public speaking even though that exposure is not the next task on his hierarchy. Additionally, regardless of the difficulty of any given exposure task, the tasks should be constructed so that maximum extinction learning can occur. More specifically, exposures should be designed in a manner that allows completion of the task to most effectively highlight discrepancies between the client’s cognitions/expectancies and the actual outcome. For example, an adolescent who believes a store clerk will think he is stupid if he asks a question, should complete exposures with a variety of store clerks and in different stores, allowing him to learn that the most common response he receives is helpfulness, not contempt. The therapist commonly assists with exposure tasks initially, but as the sessions progress, increasing independence is encouraged. Although in vivo exposures are most ideal and should be utilized whenever possible, imaginal exposures can be useful in certain situations. For example, if the adolescent expresses that their anxiety is too high to attempt a certain exposure, an imaginal exposure can be useful to help the client

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plan how to cope with the situation (i.e., by challenging thoughts that arise during the imaginal exposure, reminding himself of coping thoughts, imagining himself successfully navigating the situation). Roleplaying situations with the therapist can serve a similar purpose. Additionally, if an exposure on the adolescent’s hierarchy is not one that could feasibly be practiced during a session (e.g., asking a teacher a question during class, participating in gym class, attending a group swim lesson), both imaginal exposure and role-plays can be useful methods to prepare the adolescent for the in vivo exposure without the therapist present. As much as possible, the therapist is flexible with where the exposure activities will occur. They can occur both in the therapy clinic and in the community. The use of confederates is often helpful, particularly for exposures conducted within the clinic. Materials and props are often needed as well. For example, a whiteboard to simulate writing on the board in the classroom, food or beverages to practice eating in front of others, or a cell phone to practice speaking on the phone. Each session ends with a discussion of the exposure tasks that will be completed during the next session (i.e., so the logistics can be planned) and assignment of homework exposures.

Case example Each session begins with a review of the exposure activities that were completed since the last session, as well as any naturally occurring situations in which James utilized his skills. With only a few exceptions, James consistently completes his homework tasks. As the sessions progress, he increasingly has examples of times he remembered to practice his skills outside of the assigned tasks (e.g., “I was going to the library with Mom and my sister asked me to pick up a book she had on hold. I didn’t want to have to ask the librarian for it, so I almost had my mom do it. But I remembered the importance of not avoiding things that make us uncomfortable and I used my coping thoughts and did it myself. I kinda spoke quietly, but I was still happy I did it!”) The majority of each session is dedicated to exposure activities that allow James to implement the skills he has learned in progressively more challenging situations. All exposures are completed in vivo, but during three of the sessions, imaginal exposure and role-plays are used to prepare James for the in vivo activity. Examples of activities from James’ hierarchy include texting a friend and inviting him to get together to play lacrosse, introducing himself to a stranger (e.g., the clinic receptionist, a family in the lobby), ordering a snack in a coffee shop with the therapist, browsing in a department store while the

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therapist waits outside, asking a store clerk a question, spilling his drink while sitting in a coffee shop with the therapist and his mother. James also completed one of his goals during Session 10 by going into McDonalds alone and purchasing a McFlurry. Before each exposure task, James and the therapist: (1) plan the activity, (2) discuss how he will utilize appropriate social skills in the situation, (3) identify any anxious thoughts he is having and challenge them, (4) identify at least one coping thought, and (5) conduct an imaginal exposure or role-play if needed. Following each exposure, James and the therapist debrief and process his accomplishment. At the end of each session, James and the therapist agreed on the exposure activity that would be conducted during the next session and they touched base with his mother regarding whether they would meet at the clinic or in the community (e.g., at the mall). They also agreed on the exposure tasks James would complete for homework. Examples of some of the tasks he practiced between sessions include initiating a conversation with a peer and an adult, ordering his own food when his family is eating at a restaurant, asking a stranger for directions, meeting up with a friend to play lacrosse twice per week, talking to an extended family member on the phone, ordering and paying for his food in a fast-food restaurant with his father there.

Session 12: skill review, relapse prevention, celebration Session 12: objectives—Complete final exposure activity; review material learned in treatment; highlight progress made; discuss maintenance of treatment gains The last therapy session includes a final exposure activity, review of treatment, and a celebration of the client’s success. The final exposure activity should be appropriately challenging, but the therapist should be confident that the adolescent will experience success so treatment can end on a positive note. This exposure is conducted using the same process as the earlier session. The therapist and client then review the skills he has learned throughout treatment, and discuss how he has applied them in various situations. The therapist shares a “highlight” from treatment and encourages the adolescent to do the same. It is important to emphasize that the session should not be viewed as the end of treatment, but rather that all of the sessions have laid the foundation for continued work without the therapist’s assistance. Preventing relapse involves the continued practice of skills and continued exposure to social situations. The therapist emphasizes that everyone feels anxious sometimes, but now the adolescent has the skills to successfully navigate any new anxiety-provoking situations that arise in

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the future. With some clients, it is helpful to propose hypothetical future situations and ask how the adolescent will handle them. This can be particularly helpful if the client has not yet officially completed his goals but will be doing so soon. The session concludes with a celebration. The adolescent’s preferences should dictate what the celebration consists of and who is present (e.g., parents, siblings, other family members). Popular choices are ice cream and pizza parties. During this celebration, the therapist provides the adolescent with a certificate of completion.

Case example Both of James’ parents were present for the final session. James had successfully completed his homework exposure tasks and for his last insession exposure he called the local sporting goods store and inquired whether they sold lacrosse helmets and if they had any in stock. This task moved him closer toward his goal of trying out for the lacrosse team when the school year begins and his father expressed that he was very proud of him for completing such a mature task. The group spends a few minutes reviewing the skills James’ learned in treatment and the variety of situations he applied them in. James’ mother notes that she is very proud of him for already accomplishing his goal of ordering and paying for his own food at fast-food restaurants. The therapist discusses relapse prevention with James and his parents, specifically highlighting the importance of continued practice of the skills James has learned. They discuss James’ primary goal of trying out for the lacrosse team and how he will have a chance to accomplish it when the school year begins in 2 weeks. They process how he can use his skills to manage any anxiety that arises in that situation, and James suggests that he identify coping thoughts now and reads them every day so he will remember them during tryouts. For his celebration, James had requested ice cream cookie sandwiches which the therapist provided. The therapist, James, and both of his parents enjoy the dessert, the therapist provides James with a “therapy graduation certificate,” all three adults congratulated James on all of his progress and commended his hard work.

Potential treatment challenges Our case example here is an illustration of when therapy proceeds in an optimal fashion; however, there are a number of potential treatment challenges that can and do occur (e.g., poor homework compliance,

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complex diagnostic presentation, unhelpful parenting practices) that may alter the therapist’s approach. The information provided in this section should serve as an initial introduction to potential helpful strategies for dealing with three common challenges; however, the successful handling of these situations requires a skilled clinician with substantial training and relevant clinical experiences (for further discussion see Chapter 16: Overcoming Challenges in Exposure Therapy). Due to the anxiety-provoking nature of the exposure-based homework assignments, homework compliance can be a common challenge in therapy. A strong understanding of the psychoeducation principles— in particular, the contributing factor of avoidance to continued anxiety—is necessary for the client to recognize the importance of the work they are doing. With youth, dependent upon developmental level and cognitive abilities, this could take additional sessions and homework assignments. It is helpful to regularly ask questions throughout earlier sessions to gage their level of understanding of these principles. In addition, when assigning homework, it is helpful to ask the youth’s thoughts about the assignment; this will allow for the therapist to identify potential obstacles and problem-solve these obstacles with the youth before they leave the therapy session. It will also allow for an assessment of the youth’s understanding of the assignment’s purpose and their motivation to complete it. As illustrated in the case example, if homework is not completed, whenever possible, it is best for the therapist and client to complete the homework together in the session. However, if the homework cannot be completed in session (such as a planned exposure assignment), then the exposure should be reassigned for the following week. It is important not to allow homework to be avoided and poor homework compliance to be negatively reinforced. The therapist should also take care to ask about potential reasons the homework is not being completed and to problem-solve with the youth. Solutions will depend upon the youth’s reasons for not completing homework, but at times, even simple strategies such as having the youth write down their homework in a therapy notebook, having parental reminders of homework, or having assigned rewards for successful completion of exposures can be helpful. It is also common for a client to present with comorbid conditions or with any number of idiosyncrasies that may alter a therapist’s treatment approach. For example, SAD may present with other anxiety disorders, such as generalized anxiety disorder. In this instance, if SAD is the primary target of treatment, exposures specific to the other anxiety disorder may also be added to the exposure homework, once the client has gained a strong understanding of psychoeducation principles and has made substantial progress with social-specific exposures. If handled successfully, this may enhance generalization of skills. As referenced

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earlier, social skill deficits are common for individuals with SAD. These may be minimal as in the case example or may be more pronounced, such as in an individual with Autism Spectrum Disorder (ASD). In these instances, therapy will require additional sessions dedicated to social skill development. They also may require breaking down social skills into increasingly concrete elements, such as maintaining eye contact for so many seconds or standing so many feet away from others. In instances of ASD, the individual may also exhibit decreased social motivation, which could make therapy compliance more challenging. With decreased social motivation, greater incorporation of extrinsic rewards throughout treatment may be helpful. It is also worth noting, given the phenomenology of SAD and the range in age of onset, clients may be particularly hesitant to discuss sensitive topics with therapists. It may be necessary to incorporate additional rapport building session(s) early on dependent upon the client’s interactions with the therapist. The parents referenced in the case example were a beneficial addition to the therapy protocol; however, there may be instances in which parents engage in behaviors that are less helpful and even unhelpful to treatment progress. As anxiety is maintained by avoidance behaviors, it is common for parenting patterns to have developed to accommodate this avoidance. For example, the parents of a child who is anxious ordering food in a restaurant and talking to a store clerk may have developed habits of ordering food and talking to store personnel for their child. By doing this, the parents are allowing the child’s avoidance in these situations to be reinforced. Dependent upon the extent of the youth’s social anxiety, there may be a number of these patterns that have developed across situations, and the parents may not be aware of all of them. Even when unhelpful parenting practices are recognized, they may continue to endure. The youth’s negative reaction to anxietyproducing situations may cause the parent to engage in their own avoidance behaviors, which contribute to maintenance of these unhelpful patterns. For example, a child that is fearful of going to school may argue with their parent(s), and the parent(s) may avoid dealing with the argument by allowing their child to stay home from school for the day. Instances like this simultaneously reinforce the child’s avoidance of the situation and the parent’s avoidance of dealing with their child’s negative emotional presentation. If the child’s response to their anxiety is to cry, parent(s) may feel they are actually protecting their child by allowing them to avoid the social interaction, in particular when the case involves social skill deficits and/or challenging social situations. Addressing these unhelpful parenting patterns can be challenging, and the therapist may need to set aside time during session(s) or even schedule a separate session to discuss necessary changes to parenting practices.

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Relevant therapy manuals For more information regarding manualized approaches, there are several empirically supported protocols the reader may wish to pursue. The primary psychotherapy intervention programs are cognitivebehavioral group therapy for adolescents (CBGT-A; Albano & DiBartolo, 2007; Albano, Marten, Holt, Heimberg, & Barlow, 1995) and social effectiveness therapy for children (SET-C; Beidel et al., 2000). Both interventions take place in a group therapy format, provide psychoeducation, and include exposure exercises. In addition, both interventions incorporate social skill training components to address social skill deficits observed in this population. Although these manuals have been used primarily with groups of children or adolescents, they can be used with individuals as well. Indeed, our approach described herein with James is modeled after some of the work in these manuals as well as our own clinical experiences in working with such youth using a cognitive-behavioral approach. A recent additional cognitive therapy based individual treatment has been developed that addresses selffocused attention, negative self-imagery, and use of safety behaviors common in youths with SAD, but this approach does not include social skills training or an exposure hierarchy (Leigh & Clark, 2018).

Summary SAD involves fear of negative evaluation from others and associated avoidance of situations in which this may occur (e.g., social interactions and performance-based situations). Empirically supported interventions often address this avoidance with therapeutic exposure exercises to feared situations. This chapter provides an introduction to exposurebased therapy in SAD, with a session-by-session guide to completing exposure-based treatment of this psychiatric condition. As SAD typically manifests during adolescence, the treatment guide is specific to socially anxious youth, and the case example is of a socially anxious male adolescent. The treatment guide introduced includes 12 sessions. Of these 12 sessions, the first four involve psychoeducation as well as skill development. Much of the remaining sessions (5 11) involve exposure practice, during which the patient can continue to build upon the initial foundation of the earlier sessions with assigned exposures. The final session involves a review of treatment and a discussion of longterm maintenance of treatment gains. Although we introduce a fairly structured 12-session therapy guide in this chapter, the guide is to be implemented flexibly, with the understanding that treatment cases will

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vary in their needs, strengths, environment, and more. The clinician may need to make substantial modifications to their treatment approach dependent upon these factors, for example, spending more time on social skill development or more time working with the patient’s parent (s). In line with this, the chapter ends with an introduction to common complicating factors or treatment challenges that may arise with suggestions for addressing them.

References Aderka, I. M., Hofmann, S. G., Nickerson, A., Hermesh, H., Gilboa-Schechtman, E., & Marom, S. (2012). Functional impairment in social anxiety disorder. Journal of Anxiety Disorders, 26(3), 393 400. Albano, A. M. (1995). Treatment of social anxiety in adolescents. Cognitive and Behavioral Practice, 2(2), 271 298. Albano, A. M., & DiBartolo, P. M. (2007). Cognitive-behavioral therapy for social phobia in adolescents: Stand up, speak out therapist guide. Oxford University Press. Albano, A. M., Marten, P. A., Holt, C. S., Heimberg, R. G., & Barlow, D. H. (1995). Cognitive-behavioral group treatment for social phobia in adolescents: A preliminary study. Journal of Nervous and Mental Disease, 183(10), 649 656. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5s). Washington, DC: American Psychiatric Publishing. Beidel, D. C., & Turner, S. M. (1988). Comorbidity of test anxiety and other anxiety disorders in children. Journal of Abnormal Child Psychology, 16(3), 275 287. Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 68(6), 1072. Himle, M. B. (2015). Let truth be thy aim, not victory: Comment on theory-based exposure process. Journal of Obsessive-Compulsive and Related Disorders, 6, 183 190. Hofmann, S. G., Albano, A. M., Heimberg, R. G., Tracey, S., Chorpita, B. F., & Barlow, D. H. (1999). Subtypes of social phobia in adolescents. Depression and Anxiety, 9(1), 15 18. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593 602. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21 (3), 169 184. Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical Child and Family Psychology Review, 21(3), 388 414. McGuire, J. F., & Storch, E. A. (2019). An inhibitory learning approach to CBT for children and adolescents. Cognitive and Behavioral Practice, 26, 214 224. Ollendick, T. H., & Benoit, K. (2012). A parent-child interactional model of social anxiety disorder in youth. Clinical Child and Family Psychology Review, 15, 81 91. Ollendick, T. H., Benoit, K., & Grills-Taquechel, A. E. (2014). Social anxiety in children and adolescents. In J. Weeks (Ed.), The Wiley-Blackwell handbook of social anxiety (pp. 181 200). New York: John Wiley.

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Ollendick, T. H., & Ingman, K. A. (2001). Social phobia. In H. Orvashcel, J. Faust, & M. Hersen (Eds.), Handbook of Conceptualization and Treatment of Child Psychopathology (pp. 191 210). Pergamon. Rao, P. A., Beidel, D. C., Turner, S. M., Ammerman, R. T., Crosby, L. E., & Sallee, F. R. (2007). Social anxiety disorder in childhood and adolescence: Descriptive psychopathology. Behaviour Research and Therapy, 45(6), 1181 1191. Young, B. J., Ollendick, T. H., & Whiteside, S. P. (2014). Changing maladaptive behaviors, Part 1: Exposure and response prevention. In E. S. Sburlati, H. J. Lyneham, C. A. Schniering, & R. M. Rapee (Eds.), Evidence-Based CBT for Anxiety and Depression in Children and Adolescents: A Competencies-Based Approach (pp. 194 207). Wiley Blackwell.

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C H A P T E R

10 Exposure therapy for generalized anxiety disorder in children and adolescents Jordan P. Davis, Sophie A. Palitz, Lesley A. Norris, Katherine E. Phillips, Margaret E. Crane and Philip C. Kendall* Temple University, Philadelphia, PA, United States

Generalized anxiety disorder (GAD) is characterized by persistent and uncontrollable worry about a variety of topics (e.g., health, family issues, school, safety, minor matters, the future; American Psychiatric Association, 2013), and it has historically been identified as one of the most poorly understood (Rowa, Hood, & Antony, 2013) and difficult to treat anxiety disorders (Salters-Pedneault, Roemer, Tull, Rucker, & Mennin, 2006). Ten to twenty percentage of youth meet diagnostic criteria for at least one anxiety disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003), 2.2% of youth meet diagnostic criteria for GAD in particular (Merikangas et al., 2010), and a large majority of youth have comorbid anxiety diagnoses (e.g., Kendall et al., 2010). Despite its common occurrence, research has indicated that exposure-based cognitivebehavioral therapy (CBT) is efficacious in the treatment of GAD in youth (Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; Ladouceur et al., 2000; Read, Puleo, Wei, Cummings, & Kendall, 2013; Walkup et al., 2008). Moreover, exposure is one of the critical features of gold-standard CBT programs for youth (e.g., Coping Cat; Kendall & * We would like to thank Drs. Jennifer Podell and Sandra Pimentel for their valuable suggestions for this chapter.

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Hedtke, 2006) and has been found to be a meaningful contributor to beneficial treatment gains (e.g., Kendall et al., 2005; Peris et al., 2015). Questions remain about the exact mechanism by which exposure is efficacious (e.g., behavioral experiments, habituation, coping skills development, extinction learning, cognitive change), but there is little disagreement that exposure is central. Developing and implementing exposure tasks for youth with GAD can be an arduous process, especially for therapists with clients whose worries cannot as easily be addressed with behavioral experiments (hypothesis testing) or in vivo exposure, but it is a necessary and worthwhile process. This chapter is designed as a how-to guide that therapists can reference during the planning and implementation of exposure tasks for youth with GAD. We provide detailed and illustrative outlines for the planning and implementation of exposures for school-related and future-oriented GAD worries. Sample feared situations and appropriate exposures are provided for several other common GAD worries. The detailed outlines for school-related and future-oriented worries can be generalized to assist in the planning and implementation of exposures for other GAD worries. We also outline steps for preparing youth, family, and others for exposure tasks, as well as problem-solving strategies for the management of challenging issues that may arise. Our work is based on experience treating anxious youth, primarily using Coping Cat (Kendall & Hedtke, 2006). The strategies align with a CBT framework, which can be seen in our emphasis on procedures that have been evaluated in research including changing self-talk, problem-solving, and exposure tasks, as well as preparing for exposures and processing the exposure experience after it is completed.

Before beginning exposures Therapists are encouraged to begin laying the groundwork for exposure tasks with youth prior to actually planning and implementing them. An important first step is building rapport with youth and with their parents. Many youth do not come to therapy of their own accord, which may contribute to difficulty gaining “buy-in” from them. Increasing youth engagement and involvement is a valuable first step to gaining “buy-in” for subsequent exposure tasks. Good therapist-client rapport and buy-in are likely to improve client’s compliance with exposures, thus leading to improved therapy outcomes (e.g., Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010). Therapists are encouraged to provide youth and their parents with psychoeducation about GAD. Through this process, therapists are encouraged to normalize the experience of GAD worries and explain

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the different components of anxiety: the physical symptoms (e.g., racing heart, sweaty palms, stomachache), the cognitive elements (e.g., expecting bad things such as injury, death, or extreme embarrassment to occur), and the behavioral aspects (e.g., avoiding feared situations). The roles that avoidance and parental accommodation play in maintaining anxiety are discussed: avoiding anxiety-provoking situations might feel relieving in the moment, but it makes those situations feel more distressing in the future. Parents are taught how accommodation—changing their behavior or expectations to let the youth feel less anxious (i.e., “giving in” to the youth’s anxiety)—may offer short-term relief but bring long-term challenge. That is, accommodation lets the youth feel better in the moment, but enables avoidance and can send the message that the parent believes the situation was, in fact, too difficult for the youth to handle. Following psychoeducation but before beginning exposure tasks, it is helpful to teach youth and parents skills that they can use to reduce or cope with anxiety. These skills are taught over several weeks leading up to exposure (e.g., Kendall & Hedtke, 2006; Miller, Rathus, & Linehan, 2006). Briefly, they may include, identifying one’s signals for experiencing anxiety (anxious self-talk), which can serve as a cue for when to use strategies to reduce anxiety. Some children and adolescents find deep breathing helpful, and mindfulness practices have appeal for some adolescents. Changing one’s expectations and problem-solving can be helpful skills to bring to an exposure task. Additionally, distress tolerance can be helpful for managing anxious arousal during exposure tasks.

Developing a fear hierarchy Therapists are encouraged to collaborate with youth and their parents to create a fear hierarchy (see Tables 10.1A 10.9). A fear hierarchy is a ranked list of the youth’s fears and concerns, with the least feared at the bottom of the hierarchy and the most feared at the top. Be alert: do not fall prey to assumptions about the youth’s feared situations. Instead, collaborate with the youth to determine the nature of their fear (i.e., what the youth expects might happen). Therapists can prompt the youth to be specific. If the youth states that s/he is nervous about answering the phone at home, the therapist can collaborate with the youth to help him/her better understand the underlying fear or worry. For example, the youth may be nervous about the prospect of talking to a stranger. This added specificity facilitates a more targeted exposure for the youth. After a number of feared situations are identified (ideally 8 10), therapists and youth collaborate to assign anticipated subjective

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TABLE 10.1A School-related GAD worries. SUDs rating

Fear hierarchy

8

Getting a detention

7

Breaking an important rule in class

6

Breaking a small rule in class

5

My teacher getting mad at me in front of others

5

The teacher getting mad when I answer a question incorrectly

4

The teacher calling on me in class when I don’t know the answer to a question

4

Forgetting to read the directions to a homework assignment and doing something wrong.

3

Asking a question in class

2

Imagining what it would be like for my teacher to be really angry with me

1

Seeing my teacher get angry with another student and wondering “what if that was me?”

SUDs, Subjective units of distress. Scenario: Camila (9-years-old) has a lot of worries about her performance in school, particularly that she might do something wrong and get in trouble with the teacher. These worries are worse for her at the start of the school year, before she learns classroom rules and gets to know her teacher. As a result of her worries, she has a difficult time raising her hand in class and currently has a low participation grade.

units of distress (SUDs) ratings to each fear (see Tables 10.1A 10.9). SUDs ratings were originally developed using a scale from 0 (no distress) to 100 (highest level of situational distress; Wolpe, 1969). The Coping Cat program uses an SUDs rating scale of 0 8 (Kendall & Hedtke, 2006) in an effort to simplify the process, particularly for younger children. Providing anchors for the numbers can be helpful (e.g., cartoon faces ranging from smiling to extremely nervous; written or verbal descriptors ranging from “0 5 easy peasy” to “8 5 the scariest thing I could ever do”). Once anticipated, SUDs ratings are agreed upon and assigned, the therapist and youth arrange fears in descending order. The ordering of fears can be changed, and new fears can be added at any time. Keep in mind that fear hierarchies can be as simple (e.g., a plain list) or intricate (e.g., a colorful list with pictures written on a pyramid or a ladder) as the therapist and youth deem appropriate. Keep youth engaged in the process, including having them write or draw the list themselves. Once drafted, the therapist uses the youth’s hierarchy to develop the type

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TABLE 10.1B

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School-related GAD worries: exposure tasks.

SUDs rating

Fear hierarchy

Exposure

8

Possibly getting a detention

Run down the hallways in school

7

Breaking a rule in class

Keep talking to a friend after the teacher asks us to quiet down

6

Breaking a small rule in class

Break the no chewing gum rule in class

5

My teacher getting mad at me in front of others

Have my therapist to arrange for my teacher to get upset with me in class

5

The teacher getting mad when I answer a question incorrectly in class

Raise my hand and answer a question incorrectly on purpose

4

The teacher calling on me when I don’t know the answer to a question

Verbally run through the entire feared situation with my therapist, including as many details as possible and highlighting my feared outcome

4

Forgetting to read the directions to a homework and doing something wrong

Complete a practice worksheet without reading the directions

3

Asking a question in class

Raise my hand and ask a question in class

2

Imagining what it would be like for my teacher to be really angry with me

Have my therapist read the story I wrote out loud with me, pretending to be the teacher

1

Seeing my teacher get angry with another student and wondering “what if that was me?”

Write down a story of exactly what my teacher would say if she were angry, and read the story out loud to myself a few times a day for a week

SUDs, Subjective units of distress.

and order of exposures (see Tables 10.1A 10.9). Of note, children will vary in the ratings they assign and the extent to which they use the full range of the SUDs scale. Some hierarchies may contain feared situations with ratings from 0 to 8, whereas others may contain feared situations with ratings from four to eight. This variety is reflected in the sample hierarchies presented in this chapter. Prompting a client to generate feared situations that correspond to each rating level between 0 and 8 is unnecessary. Above all, fear hierarchies should be created collaboratively and should accurately reflect the experience of the youth.

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TABLE 10.2A Future-oriented GAD worries. Rating

Fear hierarchy

8

Going on an interview for a summer job

7

Messing up an interview for a summer job

6

Completing and submitting a summer job application

5

Getting a bad grade on a test

5

Getting a failing grade on a homework assignment (which will mean she will be a failure and will not get into college)

4

Never getting a good job, and thus being a failure

4

Not getting accepted to any college while all my friends are accepted to their top choice schools

4

Not knowing if something will go wrong in my future

Scenario: Alexis (15-years-old) spends a lot of time worrying about things that could go wrong in the future. Specifically, she worries about getting into a good university and getting a job after school. These worries become more intense when Alexis gets a bad grade on a homework assignment or thinks about having to apply for a summer job. If she does not get an A, Alexis “breaks down” and asks her mom for reassurance that she will be admitted into the college of her choice and will not be a failure. Though Alexis would like to work over the summer, the thought of going to an interview, messing it up, not obtaining a position, and thus beginning a life of failure is too upsetting for her to follow through with the application process. Additionally, Alexis worries that if she doesn’t get a summer job, she will never get a job in the future.

Planning exposures: school-related GAD worries This section outlines exposure tasks for one of the most common GAD concerns: school-related worries. We use Camila, a 9-year-old girl who worries that she might do something wrong at school and that she might get in trouble with her teacher, as an example (Table 10.1A). When planning exposures, consider using in vivo exposure and imaginal exposure both in-session and between sessions (i.e., homework; Table 10.1B). Therapists may opt to begin with imaginal exposures, but this is not required. One of Camila’s central worries is that her teacher will ask her a question in class and that she will not know the answer. An initial exposure could be to have Camila describe the classroom, and then imagine the situation in detail with the therapist. When planning such an imaginal exposure, the therapist strives to identify specific aspects of the situation that make Camila anxious and thus would be useful for Camila to imagine. For Camila, details could include the name of the teacher, the name of key classmates, where Camila is sitting, a question the teacher might ask, Camila’s internal and external reactions, the answer Camila would provide and,

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Planning exposures: school-related GAD worries

TABLE 10.2B

227

Future-oriented GAD worries: exposure tasks.

Rating

Fear hierarchy

Exposure

8

Going on an interview for a summer job

Go on an interview for a summer job at a local ice cream parlor

7

Messing up an interview for a summer job

Role-play a “bad” interview with the therapist

6

Completing and submitting a summer job application

Submit several summer job applications

5

Getting a bad grade on a test

Purposefully answer three questions incorrectly on an Algebra test

5

Getting a failing grade on a homework assignment (which will mean she will be a failure and will not get into college)

Submit a homework assignment with half of the questions blank

4

Never getting a good job, and thus being a failure

Write out a story of what it would be like to not get a good job and to be failure; add as many details as possible; Read the story aloud every day for one week between sessions

4

Not getting accepted to any college while all my friends are accepted to their top choice schools

During the session, imagine (aloud with the therapist) being in this situation; Describe this scenario with as much detail as possible.

4

Not knowing if something will go wrong in my future

Ask Mom only three reassurance seeking questions

importantly, what Camila imagines the reactions of other students would be. Planning the imaginal exposure helps prepare the therapist to guide Camila through the exposure and enables the exposure to be maximally effective. If a youth does not identify and talk about the detailed aspects of the feared situation, the exposure is less likely to be successful. In-session in vivo exposures also require planning. The therapist considers which elements of Camila’s feared situations can be simulated effectively during a session. “Effectively” here refers to the ability of the situation to elicit anxious arousal in Camila. Of note, it is important to elicit anxious arousal so that the in-session situation can mimic the “real world” and so that youth can learn that they can survive their feared situations. When planning an in-session in vivo exposure for Camila for the fear of “asking her teacher a question in class,” the therapist could

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TABLE 10.3

Performance/perfectionism GAD worries.

Rating

Fear hierarchy

Exposure

8

Getting a failing grade on a drawing

Hand in a drawing half completed, earning me a failing grade

7

Having people not recognize what I drew

Draw an apple very abstractly

6

Forgetting to add shadow to a part of my drawing

Skip the shading on an object in a picture

5

Seeing an obvious stray line in a finished drawing

Make an intentional stray line in a drawing

4

Not being able to fix mistakes in my drawing

Do a drawing carefully once

3

Not checking my drawing several times to make sure there are no mistakes

Only double-check a drawing once

2

Only spending a short amount of time on my drawings

Limit time spent on drawings (e.g., to 20 min)

2

Not spending as much time as I want on my drawings

Limit time spent on drawings (e.g., to 1 hr)

Scenario: Aidan (13-years-old) has a passion for drawing, but he worries that his pictures are never perfect, which will cause him to get a bad grade in his art class. As a result, he stays up very late every evening drawing and redrawing sketches for his art class. Aidan sometimes refuses to turn in his pictures because of worries that there is a stray line and often gets distracted thinking about how he could improve his sketches. Sometimes, he even works on his drawings during other classes. This has negatively impacted his grades both in art class and in his other classes. Preparing for the exposure: Proper preparation for exposures would include discussing Aidan’s worries about imperfectly drawn artwork, discussing what makes Aidan’s favorite artists’ work good, and challenging the idea that any piece of artwork is “perfect.”

arrange for one or two confederates (e.g., a different clinician, staff member) to play Camila’s teacher during a session and role-play the anxiety-provoking situation. For the fear of forgetting to read the directions on her homework and doing something wrong, the therapist could create a worksheet to use in a session, instructing Camila to intentionally not read the directions before completing the worksheet. Between-session exposures are considered critical to treatment as these exposures typically involve the youth engaging in the very “reallife” situations that are on their fear hierarchies. Indeed, research indicates that treatment responders (i.e., youth who experience a meaningful decrease in interfering anxiety symptoms) are more likely to have completed between-session exposures than treatment nonresponders (Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013). Between-session exposures vary in intensity. For example, an initial “real-life” in vivo exposure for Camila might involve her breaking a

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Planning exposures: school-related GAD worries

TABLE 10.4

229

Safety-related GAD worries.

SUDs rating

Fear hierarchy

Exposure

8

Having a burglar break into the house

Play “News Mad Libs” with my therapist: work with my therapist to select a news story about a burglary in my city, replacing the victims’ names with my name and my parents’ names

8

Being alone in the basement at night

Go downstairs in the basement at night for 10 min while Mom is upstairs

7

Going into the basement at night with my mom at the top of the stairs

Go downstairs in the basement at night for 5 min while Mom is at the top of the stairs

6

Having to sleep alone in my bedroom after hearing a strange noise

Use coping skills to stay in my bed when I wake up and feel nervous

5

Needing a glass of water at night and having to go downstairs to the kitchen alone to get it

Go to the kitchen alone on one night during the week to get a glass of water

4

Needing to go to the bathroom in the middle of the night

Go to the bathroom alone on two nights during the week

2

Hearing sounds outside my window at night

Wait 5 min to call out for Mom after hearing scary sounds at night; try to figure out the cause of the sound

SUDs, Subjective units of distress. Scenario: Ethan (9-years-old) experiences excessive safety worries. He worries that burglars might break into his house in the middle of the night through a window in the basement (he does not live in a high-crime neighborhood). He interprets any sound in the house as an indication that someone is entering. Ethan often calls his mother into his room at night and cannot be alone anywhere in the house after dark, which negatively affects his family, his sleep, and ability to function the next day. Preparing for the exposure: Proper preparation for exposures in this case would include sharing information about what causes scary noises (e.g., tree limbs brushing against windows, pipes knocking from temperature changes, equipment going on and off) and about how human vision adapts to the dark (i.e., when we turn off the lights, at first the dark hides things, but then your vision gets better as your eyes adapt to low levels of light).

school rule by chewing gum during her English class. Note also that imaginal exposures and simulated exposures can be completed between sessions. The therapist might ask Camila to write a one-page detailed description of what she imagines will happen if her teacher becomes very angry with her. After a review/discussion, Camila may be asked to read the story aloud to herself every day between sessions. For this type of imaginal exposure, the therapist and Camila collaborate on a guide for Camila to use when drafting the story (e.g., questions Camila may want to ask herself to elicit different levels of anxiety). The therapist may also arrange a simulated exposure in which Camila’s teacher

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TABLE 10.5

GAD worries about world affairs.

SUDs rating

Fear hierarchy

Exposure

8

Watching the news

Watch a full news program alone

7

Watching news coverage of a recent hurricane

1. Watch news coverage of a hurricane with Mom 2. Watch news coverage of a hurricane alone

5

Watching a news clip by myself

1. Watch a neutral news clip with Mom 2. Watch a neutral news clip alone

5

Hearing the news playing in a different room

Stay seated in the other room and listen to the news coverage for 10 min

4

Seeing the news on a public television (e.g., restaurant, electronics store)

Continue eating or walking in the store without trying to leave the location

3

Seeing a hurricane occur in a different city

Watch a video clip of a hurricane hitting a city

2

Reading an article about a hurricane

Read two news articles about a hurricane

1

Reading about a news event

Read two news articles about a neutral topic

SUDs, Subjective units of distress. Scenario: Jasmine (12-years-old) is overly concerned about world affairs and cannot be in the room if the television is on a news station. Jasmine reports that it is particularly distressing for her to hear news about recent weather events, especially hurricanes. She says that when she hears these stories, she worries for the rest of the day about the people who are affected, and she experiences concurrent muscle aches and irritability. Preparing for the exposure: Proper preparation for exposures in this case would include sharing an understanding of what constitutes news and how TV producers and directors intentionally select the uncommon/unusual storiesto try to lure viewers.

gets upset at Camila in front of the class. The therapist will speak to the teacher ahead of time to determine how upset the teacher will get. The aforementioned examples illustrate planning exposures based on the youth’s specific GAD worries. Exposures are best when they are individualized and targeted to the anticipated catastrophe, so as to maximally address the youth’s anxiety. For many youth, a GAD worry may need to be addressed with several imaginal and in vivo exposures, both in sessions and between sessions. Note that imaginal and in-session in vivo exposures may not always adequately trigger anxiety. In those

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Planning exposures: school-related GAD worries

TABLE 10.6 SUDs Rating

231

GAD worries about local affairs.

Fear hierarchy

Exposure

8

Going through “code blue” drills in school

Participate in a “code blue” drill in school without trying to avoid the situation

7

Watching a news report about school shootings that have occurred

Watch the news (clip) about a school shooting that occurred relatively nearby

5

Reading about an in-state school shooting

Check the newsto see if there is an instance of an in-state school shooting; Read the article each day for a week

4

Reading about a school shooting

Read a news article about a school shooting that occurred in a different state; read the article each day for a week

4

Not being able to text Dad during the day

Taper texts to Dad down gradually starting at 5 per day, ending in 0 per day

SUDs, Subjective units of distress. Scenario: Javier (14-years-old) heard about an upcoming “code blue” shelter-in-place drill at school and started to have daily worries about potential school shootings. In his effort to make it through the school day, he asks for constant reassurance from his father via text messages. In these texts, Javier asks repeated questions such as, “a school shooting won’t happen here, right?” He cannot see any reference to a school shooting on the news without experiencing severe anxiety and is starting to talk about wanting to be homeschooled. Preparing for the exposure: Proper preparation for exposures in this case would include role-plays for how the parent can react to continued need for reassurance.

cases, the focus would be placed on “real-life” between-session in vivo exposures. As part of a therapist’s exposure plan, we encourage having available several exposure options of varying intensities. These options will allow the therapist to make changes to planned exposures if a youth is reticent, or if the situation does not generate the intended level of anxiety. Take for example, Camila’s worry that there will be severe consequences if she completes her homework incorrectly after forgetting to read the instructions. An initial exposure may involve Camila engaging in an imaginal exposure in which she details the events of this feared situation for her therapist until doing so elicits less anxiety for her. Another exposure may involve completing a worksheet during a session without reading the instructions. This exposure may not be activating (i.e., it may not generate anxiety) for Camila because the worksheet is not “real” and will not be graded or shown to her teacher. Thus, a follow-up exposure might involve Camila intentionally not reading the instructions before completing her actual homework assignment. The therapist may specify that Camila is allowed to review the instructions

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TABLE 10.7 SUDs rating

GAD worries about changes in plans and new situations.

Fear hierarchy

Exposure

8

Not knowing the plan for an entire day

Spend an entire day with no set routine

7

Not having my planner for a full day

Leave my planner at home for one school day

6

Not writing everything in my planner

Write only the most important things in my planner, such as my homework assignments and upcoming test dates

6

Taking a new route

Drive to school taking a new route

5

Having my schedule be thrown off

Go to school 10 min late, thus throwing off the day’s schedule

4

Thinking about unexpected changes occurring during my day

Write a story describing what would happen if an unexpected change occurred in my schedule. Read the story aloud every day for one week.

3

Not knowing the plan for the day

Taper reassurance seeking questions from 5 to 0

SUDs, Subjective units of distress. Scenario: Jacob (10-years-old) has a very difficult time with changes to his routine and constantly writes out his schedule in a planner that he carries with him throughout the day. If he is not familiar with the route that his family is taking to get to a location or does not know what the schedule is for the day, he becomes very nervous and a bit oppositional. As a result, Jacob’s parents accommodate his distress by sticking to a strict schedule and never deviating from typical routes to each location. Preparing for the exposure: Proper preparation for exposures in this case would include working with parents to reduce the accommodation and increase Jacob’s ability to tolerate distress. The therapist might play the card game War with Jacob designating a card (e.g., seven of spades) to be the indicator that now a low card, rather than a high card, wins the war. Jacob has to tolerate the unknown timing of the change in the rules of the game.

for the homework before turning it in. A final, and most anxietyprovoking, exposure for this feared situation may be to have Camila complete and turn her homeworkassignment in without reviewing the instructions and editing her work. After planning a set of exposures, therapists are encouraged to consult with their clients. This process helps reduce the probability of having an unsuccessful exposure, as the youth will be able to provide information as to how activating a proposed exposure is likely to be. Therapists can avoid youths attempts at negotiating out of completing exposures by providing a forced choice. That is, instructing the youth to choose from three provided options for exposures. Exposure options may vary based on intensity or exposure type (i.e., imaginal or in vivo). Of note, some youth state that no provided exposure option will be

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Planning exposures: school-related GAD worries

TABLE 10.8 SUDs rating

233

GAD worries about health of self/others.

Fear hierarchy

Exposure

8

Hearing from my doctor that I need follow-up tests

Have my doctor tell me that I may be sick and will need to get some follow-up tests done

8

Going to the doctor

Go to the doctor for a physical

6

Not checking for symptoms when nervous

Taper body symptom checking from a total duration of 30 min per day to a duration of 0 min per day

5

Imagining having cancer

Write a detailed story of what it would be like to have cancer; Read the story aloud every day for one week

5

Not asking parents if I will be okay

Taper reassurance seeking from 10 questions per day to 0 questions

4

Not checking symptoms on WebMD

Taper WebMD checking from 15 times per day to 0 times per day

3

Seeing a story about people diagnosed with cancer

Read three stories about different people who have and have not been diagnosed with cancer

SUDs, Subjective units of distress. Scenario: Jayden (13-years-old) spends most of his day worrying that he might have cancer. He often asks his parents to confirm that he is not sick and spends several hours per day researching the symptoms of various diseases online. Jayden then worries about what he read online for the remainder of the day and repeatedly checks his body for new symptoms. He avoids going to the doctor’s office entirely because he is afraid to be told he is sick, even though he is long overdue for a check-up and needs to complete a physical to participate in school sports. Preparing for the exposure: Proper preparation for exposures in this case would include providing information about symptoms and their accuracy/inaccuracy in identifying disease as well asthe important topic of the tolerance of uncertainty. Under distress, one has to be able to tolerate not knowing what will happen. Additional exposures might include asking about several of the many things in life, in which the correct answer is “we don’t know.”

activating for them. In these cases, the therapist is encouraged to ask the youth to complete one of the exposures anyway. Youth often report that exposures are more activating than they thought they would be. This is often true of youth with poor insight into their experience of GAD worries. If the youth is truly not activated by an exposure, the therapist will learn that the youth can attempt a more advanced exposure in the future.

Preparing youth for specific exposure tasks After planning and consulting with the youth about exposures in general, the therapist prepares the youth for each exposure before implementation. The therapist helps the youth to identify which

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TABLE 10.9 SUDs rating

GAD worries about family issues.

Fear hierarchy

Exposure

8

Having my parents tell me they are going to get a divorce

Have my parents act out telling me they are getting divorced

7

Hearing my parents get into an argument

Watch my parents role-play two disagreements within earshot, one with a reconciliation and one without

6

Hearing my parents talk about disagreeing, agreeing, and the topic of divorce

Listen to my parents talking during a discussion about a potential divorce

5

Thinking about what would happen if my parents got divorced

Write down a story of exactly what would happen if my parents got divorced; read the story aloud every day for two weeks

4

Hearing other people talk about divorce

Watch a movie or read a storybook about a child whose parents got divorced

3

Not seeking reassurance when I worry about divorce

Taper reassurance seeking questions from 3 per day to 0 per day

SUDs, Subjective units of distress. Scenario: Mia (9-years-old) is very worried that her parents might get divorced. Any time she hears her parents become frustrated with one another, she assumes that they are going to separate, and she then spends the rest of the day worrying uncontrollably. When she has such worries, she asks her parents for constant reassurance that they will not separate and has difficulty concentrating. Preparing for the exposure: Proper preparation for exposures in this case would include some information about relationships and the fact that two people do not always agree (which does not necessarily indicate that a couple will separate). Parallels can be drawn between Mia’s parents and Mia and her own close friends (i.e., Have they ever disagreed? Are they still friends?). Exposure to the tolerance of uncertainty would be useful.

previously learned coping skills (e.g., coping thoughts, challenging negative/anxious thoughts, distress tolerance) might be most useful to him/her during the exposure. Within the Coping Cat program, this process includes discussing the physical symptoms of anxiety that the youth will likely recognize (e.g., racing heart) and identifying the anxious thoughts and feared outcomes s/he anticipates having (“My teacher will get mad at me,” “I’m going to be a failure.”) before brainstorming things that may help the youth to feel less anxious during the exposure. Distress tolerance strategies can be useful to youth with a wide variety of GAD worries. Common distress tolerance strategies include (1) progressive muscle relaxation (i.e., tensing and then relaxing different muscle groups directly before, during, or after an anxiety-provoking situation), (2) deep breathing, (3) attempting to derive meaning from the

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feared situation (e.g., “I am very nervous about getting a question wrong on purpose, but maybe doing so will help me learn how to deal with people being mad at me.”), (4) going on a run after completing an assignment without reading the instructions, (5) splashing your face with very cold water when you are feeling anxious about the prospect of not getting into college, (6) reminding yourself that your worries are just thoughts, and that you don’t have to listen to them, and (7) staying mindful in the present moment when you notice yourself worrying about any aspect of the future (therapists can help youth search for and rehearse relevant mindfulness practices). Distress tolerance strategies may also include coping thoughts such as “If I just jump into this situation, it will be over with as soon as I know it,” or “I don’t like feeling this anxious, but I can handle it.” Many of these skills are taught prior to the first exposure, during the psychoeducation portion of the Coping Cat program. An important step in preparing youth for exposure is defining a “successful outcome” and identifying the reward they will get when they complete the exposure. Recognizing that youth may be in therapy due to their parents’—and not their own—wishes, and that exposures are difficult, rewarding youth for their effort (not performance) in practicing brave behavior is an important motivator. Typically, a “successful outcome” would be that the youth completed the task, even if they were extremely nervous while doing so or changed the task a bit along the way. That is, even if Camila was red with embarrassment and shaky while answering a question incorrectly in class, it would still be considered a successful exposure—she made the effort! Youth are encouraged to discuss and arrange rewards with their parents, so that rewards can be meaningful. Youth and parents are also encouraged to consider nonmonetary rewards. For example, many youths enjoy rewards such as an extended curfew, extra time spent with Mom/Dad, creating the dinner menu, and even the feeling of being proud of themselves. Of note, parents can take care to ensure that rewards are commensurate with the intensity of the exposure. Therapists encourage and guide youth to develop a coping plan when completing exposures between sessions. Therapists highlight the importance of having ideas for how to cope with anxiety during a given situation (e.g., problem-solving a potentially anxiety-provoking situation before you become extremely anxious), as well as knowing what your reward will be ahead of time (i.e., you have something to look forward to). The therapist works with the youth to identify a “successful outcome” for each between-session exposure.

Preparing parents/family Prior to beginning exposure tasks, therapists are encouraged to discuss the exposure process with parents. Parents are warned that

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exposures may be difficult for youth, and that they may notice an increase in their child’s anxiety (or reluctance to come to sessions) at the start of the exposure process. Therapists are encouraged to describe the exposure process in detail (e.g., exposures will be gradually implemented and will occur in-session and between sessions) and to inform parents of their role during the exposure process. For example, therapists work with parents to help them notice and point out brave behavior. Parents are encouraged to remind their children to use coping skills and not to provide reassurance. Parents are encouraged not to accommodate their children’s anxious distress during the exposure, as doing so can lead to poor treatment outcomes (Hedtke, Kendall, & Tiwari, 2009). For example, Camila’s mother would be encouraged to avoid emailing Camila’s English teacher to check if Camila was too nervous to ask a question in class. Alexis’s father would be encouraged to not to repeat that “Everything will be fine. You could never be a failure (Table 10.2A).” Parents may be concerned about their own ability to stop accommodating their child’s distress. Role-play activities with parents may be useful. Here, the therapist will provide sample language that is supportive, but not reassuring (e.g., “I’m so sorry you are feeling anxious. I know that it’s hard to ask Mrs. Brown questions in class, but I also know you can do it!” rather than, “It’s okay, don’t worry about it. Mrs. Brown is not going to be mad at you. I’ll talk to her about it.”). Before finalizing and assigning between-session exposures, the therapist checks in with the parents to verify that the exposure is feasible. Planning multiple exposures can be helpful here so that a backup exposure is available if parents realize a particular exposure task is unfeasible. After exposure tasks have begun, the therapist meets with the parent(s) briefly after each session to define their role in the exposure and to clarify how they can be supportive at home. Some exposures may require direct parental instructions (e.g., “Camila is only allowed to ask you three reassurance seeking questions. For each additional question you can respond, ‘I’m sorry, honey; you already asked three questions.’”), while others may simply require reminders (e.g., “For this week’s exposure, I want you to not provide reassurance before school, but you can check in with Camila to see how her challenge went at the end of the day. Also, continue to praise her brave behavior whenever you notice it.”). As the exposure tasks progress, the therapist may begin to increase parent involvement. That is, the parents might begin to help the youth identify helpful coping skills and to reward bravery. Therapists can prepare parents by having them observe a therapist child role play.

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Preparing and coordinating with other individuals Some exposure tasks require coordination with individuals other than the youth or the youth’s parents ( e.g., teachers). This is particularly true of exposures for school-related GAD worries, but may also be true for other GAD concerns. Coordinating with a youth’s teacher can help facilitate exposures, such as having Camila’s English teacher get upset at her and having Alexis’s teacher tell her that she may never go to college. In some cases, communication with the teacher may also be necessary to ensure that exposures will not significantly hurt the youth’s grade. For example, when assigning Camila the exposure task of turning in homework without having read the instructions, speaking with her teacher beforehand is needed to confirm that the task will not be truly detrimental to her. It is helpful to talk with teachers about the aims and goals of exposure so that they are aware of the rationale for the youth’s behavior. Collaborate when possible: teachers may have helpful ideas for exposures. It may be useful to coordinate with other individuals that may increase the authenticity and success of an exposure. For example, Alexis’s therapist might find it useful to contact a local ice cream parlor to see if a staff member is willing to conduct an authentic mock job interview.

Planning exposures: future-oriented GAD worries This section outlines planning and implementing exposures for future-oriented GAD worries. As an example, we use Alexis, a 15-yearold female who is worried that something will go wrong in her future, that she won’t get into college, that she will be a failure, and that she won’t be able to obtain a summer job (Table 10.2A). All of the principles mentioned in the Planning Exposures: SchoolRelated GAD Worries section above can be applied to the planning of exposures for future-oriented GAD worries. As discussed in relation to school-related GAD worries, therapists should plan in vivo, imaginal, in-session, and between-session exposures (Table 10.2B). Many of the exposures highlighted for Camila’s school-related GAD worries were in vivo exposures that occurred both in and between sessions. However, therapists will often find that, due to the abstract nature of future-oriented GAD worries, as well as the fact that they are less amenable to problem-solving, imaginal exposures are often the preferred exposure type when treating youth with future-oriented GAD worries. One of Alexis’s main worries is that she will never get a good job and will end up being a failure. There is no way to prove that this will not happen, and there is no way to carry out an in vivo exposure in

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which Alexis is in the future with a good job. Imaginal exposures offer a viable method to address Alexis’s fear. When planning exposures for future-oriented worries, the therapist will attempt to identify both the specific and the global features of the youth’s fears. For example, Alexis worries about specific things such as getting a bad grade, not getting a summer job, and not getting into college. However, she also expresses some global concerns that these worries feed into, such as “being a failure.” Where possible, therapists are encouraged to address both specific and global worries. Specific concerns may be best addressed with in vivo exposures. For example, one exposure might involve Alexis interviewing people who she sees as “not a failure” and asking them if they ever got a bad grade on an Algebra test. Through this exposure, Alexis tests her anticipated catastrophe and is likely to learn that at one point or another, everyone—including people with good jobs—has done poorly on an examination. Another exposure might involve having Alexis apply for a summer job. Alexis demonstrates extreme anxiety at even thinking about applying for a summer job, so this exposure may need to be broken down. For example, the therapist could first have Alexis complete an in-session imaginal exposure focusing on a scenario in which she applies for a summer job. The therapist might then have Alexis complete an imaginal exposure in which she discusses the positions she is interested in applying for. Exposures could eventually progress to an in-session role-play of a job interview in which Alexis intentionally messes up the interview, and perhaps another in which she handles the interview very well. The therapist can arrange a higher intensity simulated exposure in which Alexis completes a prearranged, but realistic, interview with a local business owner. Of course, the highest level exposure for this feared situation would be for Alexis to apply for a job and complete a real interview. However, the therapist is not at liberty to make this situation occur. Thus, it is important to have multiple highintensity exposures planned. Global worries such as being a failure are harder to address using in vivo exposures; however, they can easily be addressed using imaginal exposures. For example, the therapist could have Alexis write out a story about being a failure, detailing what would happen to her at every step of the way. Once complete, the therapist could then have Alexis read the story aloud (in session and between session) until it elicits less anxiety. Simulated in vivo exposures may also be useful when addressing future-oriented GAD worries. For example, the therapist could have a confederate pose as a teacher handing back a failing homework assignment. The therapist could arrange for the confederate to have a serious conversation with Alexis informing her that she will never be accepted

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into college based on her performance on this one homework assignment. It is highly unlikely that such a scenario would ever occur; however, this role-play may activate Alexis’s anxiety and provide an opportunity for active coping. If possible, the therapist could arrange to have one of Alexis’s actual teachers conduct the same exposure with her at school. Another simulated exposure might involve having Alexis’s parents type up several realistic college rejection letters (and an acceptance letter) and mailing them to their home, so that Alexis can receive, read, and practice coping with them. Youth with both school-related and future-oriented GAD worries often seek reassurance from their parents. For example, Alexis frequently seeks reassurance from her father that everything will be okay and that nothing bad will happen in her future. A series of in vivo exposures in which Alexis slowly decreases the number of reassurance seeking questions she asks her father may be warranted here. The therapist could have Alexis start off with asking only five questions per day, followed by only two, and finally zero questions. As with all exposures, the starting point for allowable reassurance seeking is individualized.

Implementing exposure tasks Once therapists have planned several options for exposures; prepared the youth, family, and others; and verified that upcoming planned exposures are feasible, exposure implementation can begin. When implementing exposures, therapists verify that the youth and others are aware of what will take place, so that the exposure will go smoothly. Therapists collect SUDs ratings during the exposure. SUDs ratings help therapists identify how activating a given exposure is for the youth. The ratings also help youth to see how their experience of anxiety changes over time. In an ideal exposure, youth discover that their SUDs ratings decrease over the course of the exposure. As exposures are repeated, youth ideally find that their SUDs ratings decrease. In order to help to create this effect, it is recommended that therapists wait to end an exposure task until a time when youth experience a SUDs rating decrease (e.g., 50%). Exposure termination will be determined using the therapist’s judgment. For example, therapists make adjustments in instances of an extremely activated client. However, whenever possible, therapists do not discontinue exposures until the youth’s SUDs rating has decreased. If a client’s SUDs rating is not decreasing at all throughout an exposure, therapists may consider assigning exposures of lower intensity.

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It may be useful to create charts to help clients track their completion of between-session exposures. Charts remind youth of the assigned exposure and serve as a visual reminder of how close they are to getting their planned reward. Charts can be basic or intricate; they are individualized to each youth and include details specific to his or her practice. A quality chart will contain, at the minimum, the assigned exposures, areas to check off completion of the exposure, and a reminder of the planned reward. After an exposure is complete, the therapist and youth “process” the experience, as post-processing facilitates positive gains (Tiwari et al., 2013). Therapists may simply ask their client for an overview: “How do you think it went?” Therapists can also ask more specific questions: “Did what you feared would happen actually happen?” SUDs ratings provide a good tool to begin this discussion. Therapists may find it helpful to ask youth what thoughts they were having when their SUDs rating was highest and what thoughts they were having when their SUDs rating was lowest. Ask youth what skills helped them to cope during the exposure. If the exposure had been completed before, the therapist can compare the current exposure experience with the past one (e.g., which was easier, what made it easier, what was learned from one exposure to the next).

Problem-solving potential difficulties Exposures are challenging for youth, but they can also pose difficulties for therapists: be prepared to help manage potential difficulties. One difficulty emerges when an exposure that seemed to be at an appropriate difficulty level ended up being too difficult when the youth attempted to complete it. The therapist can “back up” but not “back down.” In this situation, work to make the exposure slightly less demanding, so the youth can be successful. That is, the goal is to have the youth still engage in the exposure, even if it has to be made easier. Over time, the therapist and youth collaborate and get to a point when the original exposure can be completed. As appropriate, the therapist works with the parents to help them modulate exposure intensity for between-session exposures. The markers for this decision are individualized. If youth become discouraged after a difficult exposure, remind them that valuable information is learned from every exposure. In the case of a less successful exposure, the therapist and youth learn that a feared situation is more anxiety-provoking than anticipated. This lesson is not a core failure on the part of the youth. The youth can also be reminded that now both the therapist and the youth know what the youth needs to practice.

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Another potentially difficult situation for therapists is when a youth refuses to do a previously agreed upon exposure. The therapist then determines the reason for the refusal. Is s/he nervous? Does s/he think the exposure process is silly? Is the anticipated catastrophe believed to be likely? Does s/he need a few minutes to prepare? Once the reason is identified, steps can be taken to re-engage the client. For example, if the client reports being too nervous to even try the exposure, the therapist can problem-solve with the youth to determine what might make the exposure more tenable. The therapist can remind the youth that they will be rewarded for making an effort to engage in brave behavior.The therapists may also find it useful to change features of the exposure (decrease the intensity) such that the client will likely succeed. Success in completing an exposure task typically leads to confidence boosts for the youth. If the youth thinks the exposure process is silly, this may be an instance of “verbal behavior as avoidance.” By saying it’s silly or unnecessary, the youth anticipates being able to avoid having to do it. In some instances, it is helpful for the therapist to discuss the rationale behind exposure, particularly as it relates to the youth’s specific GAD worries. They can increase buy-in by sharing a research article about exposure treatment or reminding the youth that they can earn rewards for completing exposures. When the youth simply needs time to calm down, the therapist can validate the distress, problem-solve, and then continue with the exposure.

Sample GAD fear hierarchies and suggested exposure tasks Seven cases involving GAD worries are provided (Table 10.3 10.9). Examples include the fear hierarchies, level of anticipated difficulty, and suggestions for exposure tasks.

Conclusion Although the development and implementation of exposures can seem like a daunting task, research has indicated that exposure-based therapy is efficacious for the treatment of GAD (e.g., Kendall et al., 2005, 2008; Ladouceur et al., 2000; Read et al., 2013; Walkup et al., 2008). When planning exposures for youth with GAD worries, therapists consider developing imaginal, in vivo, in-session, and between-session exposure tasks. Exposures are highly individualized, and although therapists plan exposures in advance of each session, they can change the details of a planned exposure during the exposure if doing so will be beneficial to treatment. Above all, therapists engage their clients

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throughout the therapeutic process to identify the specifics of the youth’s feared situations and feared/unwanted outcomes.1 Exposure tasks provide opportunities for youth to implement skills they have acquired, discover that some anticipated negative outcomes did not occur, and build confidence in their ability to manage and tolerate anxiety-provoking situations in the real world.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60, 837 844. Available from https://doi.org/10.1001/archpsyc.60.8.837. Hedtke, K., Kendall, P. C., & Tiwari, S. (2009). Safety-seeking and coping behavior during exposure tasks with anxious youth. Journal of Clinical Child and Adolescent Psychology, 38, 1 15. Available from https://doi.org/10.1080/15374410802581055. Kendall, P. C., Compton, S., Walkup, J., Birmaher, B., Albano, A. M., Sherrill, J., & Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety Disorders, 24, 360 365. Available from https://doi.org/10.1016/j. janxdis.2010.01.009. Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing. Kendall, P. C., Hudson, J., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76, 282 297. Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12, 136 148. Ladouceur, R., Dugas, M. J., Freeston, M. H., Le´ger, E., Gagnon, F., & Thibodeau, N. (2000). Efficacy of a cognitive behavioral treatment for generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957 964. Available from https://doi.org/10.1037/0022-006X.68.6.957. Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated metaanalysis. Cognitive Therapy and Research, 34, 429 438. Available from https://doi.org/ 10.1007/s10608-010-9297-z. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980 989. Available from https://doi.org/10.1016/j.jaac.2010.05.017. Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press. 1 For additional information on implementing exposures for anxious youth see: Peterman, Read, Wei, and Kendall (2015). The art of exposure: Putting science into practice. Cognitive and Behavioral Practice, 22, 379 392.

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Peris, T., Compton, S., Kendall, P. C., Birmaher, B., Sherill, J., March, J., . . . Piacentini, J. (2015). Trajectories of change in youth anxiety during cognitive-behavior therapy. Journal of Consulting and Clinical Psychology, 83, 239 252. Peterman, J., Read, K., Wei, C., & Kendall, P. C. (2015). The art of exposure: Putting science into practice. Cognitive and Behavioral Practice, 22, 379 392. Available from https://doi. org/10.1016/j.cbpra.2014.02.003. Read, K. L., Puleo, C. M., Wei, C., Cummings, C. M., & Kendall, P. C. (2013). Cognitivebehavioral treatment for pediatric anxiety disorders. In R. A. Vasa, A. K. Roy, R. A. Vasa, & A. K. Roy (Eds.), Pediatric anxiety disorders: A clinical guide (pp. 269 287). Totowa, NJ: Humana Press. Available from https://doi.org/10.1007/978-1-4614-65997_13. Rowa, K., Hood, H. K., & Antony, M. M. (2013). Generalized anxiety disorder. In W. Craighead, D. Miklowitz, & L. Craighead (Eds.), Psychopathology: History, diagnosis, and empirical foundations (2nd ed., pp. 108 146). Hoboken, NJ: John Wiley. Salters-Pedneault, K., Roemer, L., Tull, M. T., Rucker, L., & Mennin, D. S. (2006). Evidence of broad deficits in emotion regulation associated with chronic worry and generalized anxiety disorder. Cognitive Therapy and Research, 30, 469 480. Available from https:// doi.org/10.1007/s10608-006-9055-4. Tiwari, S., Kendall, P. C., Hoff, A., Harrison, J., & Fizur, P. (2013). Characteristics of exposure sessions as predictors of treatment response in anxious youth. Journal of Clinical Child and Adolescent Psychology, 42, 34 43. Available from https://doi.org/10.1080/ 15374416.2012.738454. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S., Sherrill, J., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359, 2753 2766. Available from https://doi.org/10.1056/NEJMoa0804633. Wolpe, J. (1969). The practice of behavior therapy. New York: Pergamon Press.

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C H A P T E R

11 Exposure with response prevention for obsessivecompulsive disorder in children and adolescents Monica S. Wu1, Hardian Thamrin2 and Jocelyn Pe´rez3 1

UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, United States, 2Department of Psychology, Arizona State University, AZ, United States, 3Children’s Hospital Los Angeles, CA, United States

Exposure therapy for obsessive-compulsive disorder in children and adolescents Obsessive-compulsive disorder (OCD) is a psychiatric disorder affecting approximately 1% 2% of children and adolescents (Geller, 2006; Zohar, 1999). It is characterized by the presence of obsessions (intrusive and distressing thoughts, sounds, images, or impulses) and/ or compulsions (repetitive rituals, either mental or overt behaviors; American Psychiatric Association, 2013). These symptoms can manifest in myriad ways, given the heterogeneous presentations of childhood OCD (Stewart, Rosario, et al., 2008; Stewart et al., 2007). For instance, one child may possess contamination-related fears that cause them to compulsively wash their hands after touching public items (e.g., doorknobs, countertops). Meanwhile, another child may present with more symmetry-related concerns, needing everything to be evened up

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(e.g., socks must be at equal height, spoon and fork must be placed precisely on each side of the plate). As such, it is important to recognize that symptoms may present in a multitude of ways in youth with OCD. Pediatric OCD has been associated with significant functional impairment across a variety of life domains (Storch, Larson, et al., 2010). Indeed, youth with OCD often experience interference in their social, familial, and academic functioning (Piacentini, Bergman, Keller, & McCracken, 2003; Piacentini, Peris, Bergman, Chang, & Jaffer, 2007). Given these deleterious effects, it is imperative that these youth receive the optimal, evidence-based intervention in a timely manner. Based on practice parameters set forth by the American Academy of Child and Adolescent Psychiatry, exposure and response prevention (ERP) is recommended as the front-line therapy for pediatric OCD (American Academy of Child and Adolescent Psychiatry, 2012). Indeed, numerous randomized controlled trials have demonstrated the efficacy of ERP (McGuire et al., 2015; The Pediatric OCD Treatment Study (POTS) Team, 2004), supporting its use in the treatment of childhood OCD. As such, it is important for clinicians and researchers alike to understand how to best implement this treatment through comprehending the rationale behind ERP, learning how to effectively conduct ERP in a systematic, personalized manner, and knowing how to address potential barriers that may complicate ERP.

Background of treatment approach ERP is a type of cognitive-behavioral therapy (CBT) that focuses primarily on the behavioral aspects of treatment. First, CBT is broadly based on the tripartite model of the interplay between thoughts, feelings, and behaviors (Benjamin et al., 2011); in this model, each component is proposed to bidirectionally influence one another (e.g., thoughts impact how you feel, feelings impact how you behave). This model is important to consider when conceptualizing the maintenance of obsessive-compulsive symptoms in youth, which occurs through a negative reinforcement cycle (Piacentini, Langley, & Roblek, 2007). Specifically, when a child experiences an obsession (e.g., “my hands are dirty and I’m going to get sick”), they experience an uptick in their level of discomfort, anxiety, or disgust. Consequently, they engage in compulsions in response to this obsession (e.g., immediately washing their hands five times to get rid of the perceived germs), successfully decreasing their distress in that moment. In this model, the compulsions are negatively reinforced because it takes away their discomfort in that moment, making it more likely for the child to continue engaging in the compulsions whenever they experience those obsessions in the future. As such, the only thing they learn in this OCD cycle is to engage in their compulsions in

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order to get rid of their obsessions and attenuate the anxiety/discomfort. Consequently, treatment seeks to break this negative reinforcement cycle through something called “exposures” and “response prevention.” The primary component of ERP is “exposures.” When doing exposures, youth are encouraged to face the thoughts and situations that make them uncomfortable in a systematic and gradual manner. For instance, a child with contamination-related concerns would be asked to touch a public doorknob, or an adolescent with rewriting compulsions would be instructed to write a sentence all the way through only once. With the exposure, it is imperative that “response prevention” occurs as well. More specifically, youth are instructed to refrain from engaging in their compulsions when completing exposures. Taking the aforementioned examples, a child with contamination-related concerns would be discouraged from washing their hands after touching the doorknob, and the adolescent would be expected to not erase and rewrite the sentence repeatedly. The purpose of ERP is to break the OCD cycle by allowing the child to witness what would happen if they did not engage in their compulsions. This facilitates the formation of new, stronger associations between the triggering stimulus (e.g., public doorknobs) and the more realistic consequence (e.g., not getting sick, even without the use of hand sanitizer). By facing these feared situations, these youth are able to violate expectancies and learn that what they feared was unlikely to occur, or that they were able to at least tolerate the distress (Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Furthermore, ERP is designed to teach the child more adaptive ways of coping with their distress, rather than cyclically engaging in their rituals. By repeatedly engaging in these exposures in multiple situations and with varying difficulty levels, the child will eventually learn how to confront their OCD-related fears without needing to engage in their compulsions to attenuate their distress. Collectively, it is evident that breaking the OCD cycle necessitates consistency, repetitions, and perseverance in the face of distress. Consequently, support from the family will be imperative in the treatment of childhood OCD, particularly given the age of these youth. It is broadly the case that CBT with youth often requires the assistance of a caregiver, as youth are always assigned therapy homework to complete in between sessions in order to solidify the skills learned in treatment. This holds true for ERP as well, especially given the distressing nature of the homework tasks (i.e., exposures) and the need for caregiver monitoring. However, familial inclusion is also recommended so the caregivers can provide supportive coaching to help facilitate the completion of exposures (Lewin & Piacentini, 2009). Additionally, the involvement of family members will help ensure that they are able to learn how to

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model appropriate reactions and avoid accommodating the child’s symptoms, which is essential for optimizing success with ERP.

Chronology and components of exposure therapy for obsessivecompulsive disorder When families initially present to a therapy session for ERP, setting a solid foundation regarding the expectations and rationale behind this treatment is imperative. By dedicating time at the forefront to discuss these pieces of information, it will help assure that all parties are in agreement with the treatment plan, ascribing a purpose to each therapeutic task and enhancing motivation for engaging in therapy. Once the psychoeducational foundation is established, a personalized treatment blueprint is created with the family; triggering thoughts and behaviors related to the child’s OCD will be reviewed methodically in order to create an objective treatment plan. Once established, treatment will transition to the introduction and practice of coping skills in identified OCD-related situations. Thereafter, the remainder of the sessions will be dedicated to conducting exposures, which are the core component of ERP and should thus comprise the majority of treatment. Once substantial symptom reduction is observed, sessions are down-titrated in frequency, and relapse prevention and booster sessions occur toward the end of treatment. The specific details of each component of ERP are listed below in chronological order.

Components of psychoeducation Regarding the actual elements of psychoeducation, clinicians should first provide a general introduction to OCD. Specifically, defining obsessions and compulsions, and providing common examples of each will help place the symptoms in context for the family. For instance, obsessions can be described in a developmentally appropriate manner by introducing them as “thoughts, pictures, or impulses that come into your head over and over again and bother you.” Compulsions can be presented as “behaviors that you feel like you have to do over and over again until you feel better.” Examples of symptoms can span across various subtypes (e.g., contamination, aggressive) and should be tailored toward the child’s specific presentation. For instance, a child with “just right” symptoms may be provided with an example of someone who needs to pace in and out of a doorway until it feels “right” to them, or else they feel uncomfortable. By personalizing psychoeducational

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materials, families are more likely to be engaged and feel understood in therapy. A general presentation of the prevalence and etiology of pediatric OCD will be helpful for the family to better understand why these symptoms develop and how common they are. By referencing the prevalence rate, youth often feel less ostracized and can be surprised at how many of their peers may present with similar symptoms. Indeed, it is helpful to ask the patient to calculate how many youths in their school are likely to also have OCD, allowing for a concrete example of the incidence rates of pediatric OCD (Piacentini, Langley, et al., 2007). Regarding the etiology, caregivers often display a curiosity as to why their child developed OCD. It is important for the family to understand that there is not a singular, definitive cause of this disorder, but rather a multifaceted convergence of factors. Specifically, families should be informed that pediatric OCD typically develops due to a confluence of factors (genetic, environmental, biological). Pediatric OCD does have a genetic component, in which children of parents that have OCD are at higher risk of developing OCD (International Obsessive Compulsive Disorder Foundation Genetics Collaborative (IOCDF-GC) and OCD Collaborative Genetics Association Studies (OCGAS), 2017; Mattheisen et al., 2014); however, it is important to note that it is not a one-to-one ratio, so a parent that has OCD may not have a child with OCD, and vice versa. There are also environmental factors that may contribute to the pathogenesis of OCD; some individuals may have an event that triggers development of obsessive-compulsive symptoms (e.g., flooding the house after not turning off the faucet, leading to compulsive checking of sinks) or certain family factors in their immediate environment (e.g., parent imparting certain dysfunctional beliefs, such as overestimating threat). There are also biological factors that can partly contribute to the development of symptoms, such as abnormalities with brain circuitry (Modell, Mountz, Curtis, & Greden, 1989; van den Heuvel et al., 2005, 2011), as well as with chemicals in the brain, such as serotonin (Hu et al., 2006; Mundo et al., 2002) and potentially glutamate (O’Neill et al., 2017; Wu, Hanna, Rosenberg, & Arnold, 2012). With families that perseverate about the causes of OCD, validating and normalizing their desire to understand the causes of the disorder can help mitigate some distress. More importantly, emphasizing the present and describing how treatment can help target the current symptoms and lead to improved outcomes will help redirect the family’s focus, harnessing their energy to be more action-oriented. After defining what OCD is and what contributes to the development of symptoms, it is important to present how OCD is maintained through a negative reinforcement cycle (Piacentini, Langley, et al., 2007). Specifically, the cycle initiates with an obsession, causing an

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uptick in the child’s discomfort or anxiety. Thereafter, the urge to engage in compulsions increases and eventually leads to the child completing the ritual. The distress is then attenuated in the short term, negatively reinforcing the obsessive-compulsive symptoms. Consequently, the OCD cycle is reinforced in the long term and the child is not able to learn other ways to manage their distress (beyond engaging in compulsions), which also prevents them from experiencing what would have happened if they did not engage in their compulsions. To help reinforce this concept, personalizing the cycle and plugging in the child’s specific symptoms can assist the family with visualizing how the symptoms are being maintained. It is also helpful to highlight that behaviors beyond overt compulsions can maintain this cycle, such as avoidance and family accommodation (which are discussed at length in the sections given subsequently). The general idea is to review what behaviors will make it more likely for their OCD to be maintained, and to be vigilant about what may inadvertently feed into the symptoms. Once this negative reinforcement cycle is established, ERP should be presented as the mechanism by which the cycle will be broken. Families should recognize how ERP will break this perpetual cycle by weakening the link between obsessions and compulsions. Specifically, by exposing the child to the obsessions and feared situations without engaging in the compulsions, the child is able to learn how to manage their discomfort and see what happens if they do not do their compulsions. By refraining from engaging in compulsions, these behaviors are no longer being reinforced because the child is able to recognize other ways to manage their anxiety and learn how to tolerate the distress in other ways, weakening the bond between obsessions and compulsions. Of note, when explaining the role of exposures, it is not uncommon for families to display anxiety and hesitation about engaging in exposures, given the inherently anxiety-provoking nature of these activities. As such, establishing the rationale for doing exposures is paramount to facilitate the family’s commitment to therapy. A values-based approach by reviewing the ways in which OCD is interfering with the child’s daily functioning can be very helpful in enhancing family engagement. For instance, if the child is not able to complete homework assignments because of their compulsive rereading and rewriting, highlighting the long-term gains through short-term discomfort can help the family appreciate the broader goals of therapy. Additionally, it should be established early on that exposure therapy for pediatric OCD largely employs a family-based approach (Lewin & Piacentini, 2009). That is, the inclusion of family members in treatment will help maintain consistency in how to adaptively respond to obsessive-compulsive symptoms (e.g., disengaging from symptoms), allow monitoring of homework compliance, and ensure that the child is receiving appropriate

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encouragement and support in completing exposures in between sessions. Ultimately, families should come away with an understanding that all members of the family should be actively engaged in treatment to ensure that the child is getting maximal support for conquering their OCD. At this point, it is imperative that the clinician checks in with the family to ensure that they have a solid understanding of what OCD is, how it is maintained, and how exposure therapy will help alleviate symptoms. It is essential that the family understands the rationale behind the treatment (especially exposures) in order to enhance their motivation and compliance with the forthcoming therapeutic tasks. This is also important for the purposes of debunking erroneous beliefs about exposure therapy, as caregivers may fear that the symptoms will get worse or that it will be intolerable to go through with them. Even clinicians may present with concerns about exposure therapy in general, anticipating deleterious consequences and staying away from these treatment components. However, research has not supported these fears, as youth and their parents did not demonstrate any differences in attrition, therapeutic relationships, or satisfaction with therapy when comparing youth receiving exposure- and nonexposure-based therapy (McGuire, Wu, Choy, & Piacentini, 2018). Ultimately, by ensuring that the initial foundation in ERP for OCD is established, the clinician can team up with the family to collaboratively help the child better manage the OCD.

Constructing a fear hierarchy Once the family has acquired a foundation of the phenomenology and etiology of OCD, as well as the rationale behind exposure therapy, a personalized treatment blueprint should be constructed together with the family. Specifically, a fear hierarchy lists the child’s OCD-related thoughts and behaviors in a systematic manner, starting with the least distressing items and gradually progressing up to the harder situations. To establish one, the caregiver, child, and therapist will work together to list out all of the symptoms and create a plan for what and how to target them in treatment. Once a list of the triggering thoughts and situations are created, each item should be rated in terms of how much discomfort they cause the child. The Subjective Units of Distress Scale (SUDS; Wolpe, 1973) is typically used to numerically rate how distressing a situation is for the respondent, with 0 being not distressing at all and 10 indicating the highest level of distress possible. By rating each item on the fear hierarchy, the symptoms can be ranked from least distressing to most

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distressing. It is important to note that the fear hierarchy serves as a template for how treatment will progress. As it is not a rigid list that is “locked in,” it is normal for symptoms to change and for new OCDrelated behaviors to arise later on in treatment, so these symptoms should be incorporated into the fear hierarchy accordingly. As such, the clinician should demonstrate flexibility and make sure to update the fear hierarchy as much as is needed. Additionally, each hierarchy item can likely be broken down into many different iterations (e.g., touching a toilet seat with a pinky finger vs a whole hand, touching a toilet seat for 10 seconds with one finger versus for a minute with a whole hand). This is particularly important to remember when conducting exposures, as this could help youth ease into various exposures and enhance compliance. The fear hierarchy serves multiple purposes in treatment. For one, it is a visual and objective way for the family and the clinician to track progress in therapy. Although it is important to check back in with the hierarchy with each therapy session, it can also be helpful to review the progress made on the fear hierarchy (i.e., items addressed in treatment) to reinforce the family’s efforts and progress. Additionally, listing the symptoms from the outset provides a good overview of what the treatment targets will be and ensures that important symptoms are not overlooked once therapy begins. The fear hierarchy also allows the child to work on relatively easier symptoms first, which can be particularly helpful for buy-in and increasing motivation for the rest of treatment. By beginning on lower difficulty items on the hierarchy, the child is able to build confidence in their ability to progress with this treatment model and confront situations that make them uncomfortable, allowing them to also practice management of their distress in easier situations. Please see Tables 11.1 and 11.2 to view two sample fear hierarchies for patients that have different OCD symptom presentations (i.e., checking compulsions and sexual obsessions). Once a thorough hierarchy is obtained, the child will learn various ways to better manage their distress when obsessive-compulsive symptoms arise.

Coping skills Because ERP is designed to have the child confront situations that make them uncomfortable, it is helpful to teach the child some coping skills to use when they feel distressed. To help enhance motivation, one helpful coping tool is to have the child/family remind themselves why they are in treatment in the first place; this may help motivate them to engage in the exposure exercises, despite the discomfort caused by exposures. The reasons could be manifold, but families often pursue

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TABLE 11.1 appliances.

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Exposure hierarchy for checking compulsions related to household

Feared situation

SUDS

Cook something on the stove that requires a continual simmer for extended hours; leave the house without adjusting/checking the burners

10

Leave the house for a few hours with no one home, without checking any household appliances

9

Cook something on the stove, turn off the burner, and immediately leave the kitchen; no checking for the rest of the day

9

Leave the house without checking the stove and recite a detailed script about how the house will burn down due to a fire

8

Read a detailed script about your house burning down due to household appliances catching on fire

7

Have other members of the family use various household appliances, but refrain from going into the kitchen to check them

6

Use a hair straightener and leave it on while stepping out of the bathroom for 5 minutes

6

Read real news stories of houses burning down due to household appliances; Look at pictures of burned houses

5

Turn the stove on, then off, without checking the burners for 1 minute

5

Say “The house might burn down because I didn’t check the stove”

4

State out loud “The house might burn down”

3

Write words like “burn,” “flame,” “ash”

2

SUDS, Subjective Units of Distress Scale.

treatment because the OCD symptoms are interfering in the child’s daily functioning in some way, such as with attending school, with their friends, or with home life (Piacentini, Peris, et al., 2007). For instance, a child with contamination fears that is struggling with moving onto harder exposures (e.g., touching the sink at a public bathroom without engaging in extensive handwashing rituals) could be better motivated to proceed in treatment after thinking about the related social impairment that the teenager wants to overcome (e.g., avoiding social outings for fear of engaging in extensive handwashing rituals). Asking the child to explain why the specific exposure was chosen for their particular OCD symptom can also help reinforce the rationale behind the specific task they are doing, assigning a purpose to the behavior. This can be particularly helpful for youth who appear to just be going through the motions or exhibit confusion about the task at hand; by highlighting the specific link between the exposure and the targeted

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TABLE 11.2 parent.

Exposure hierarchy for compulsions related to sexual obsessions about a

Feared situation

SUDS

Read sexual script involving mother aloud to mother, with eye contact

10

Read sexual script aloud to mother without facing her or making eye contact

9

Read sexual script aloud to someone (not mother)

9

Write a sexual script about having sex with mother

9

Give mother a kiss on the cheek

8

Give mother a front-facing hug

7

Holding hands with mother

6

Read news article on incest aloud to mother

6

Read a news article on incest between a mother and son

5

Write out phrases like “sex with mom”

4

State words like “sex,” “penis,” “vagina” out loud

3

Write words like “sex,” “penis,” “vagina”

2

SUDS, Subjective Units of Distress Scale.

OCD symptom, the task becomes much more meaningful, and in turn, serves to enhance motivation. Cognitive restructuring is not typically emphasized in ERP, particularly because there is a fine line between modifying unhelpful thoughts and having it turn into a compulsion in and of itself (e.g., excessive self-reassurance). For instance, in an effort to calculate more realistic odds of actually contracting an illness, a child with contamination fears may in turn compulsively calculate the probabilities of contracting various illnesses and focus on the possibilities of becoming sick. Instead, it can be helpful to simply label OCD as an external entity in order to form a common target for the family to address in treatment, especially if the family has had difficulty separating the disorder from the child (and thus blaming the child for doing the OCD-related behaviors). Otherwise, much of the “meat” in ERP is focused on exposures, and most of the therapeutic tools are purposed to support the completion of exposures. It is particularly important to note that coping skills are not meant to reduce OCD-related distress in the middle of exposures; experiencing the distress while doing exposures is critical for the child’s learning, so the coping skills are more to help with general management of symptoms and facilitation of exposures.

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Conducting exposures Once the fear hierarchy is established and coping skills are acquired, the treatment can transition into conducting exposures. When starting new exposures, the therapist typically states the exposure to be conducted and then first models the exposure for the child, before the child tries it out themselves. The caregiver should be shadowing these exposures as much as possible, as they will be the ones coaching their child through the home-assigned exposures. Exposures are typically completed in order from easiest to hardest, in order to make the process more palatable and to enhance compliance. Additionally, by completing the lower level items first, the child will be able to develop confidence in completing these tasks and can practice using coping skills in less distressing environments. The following dialogue is a typical exchange between a therapist and a child hearing about exposures for the first time:

“Child

You want me to do what? There’s no way that I’m going to be able to get rid of all of my checking rituals before leaving the house. It’s just not possible— I’m going to go crazy!

Therapist

It can be pretty scary to think about getting rid of all of your compulsions at once! That’s why I won’t ask you to do that, and will instead plan to do exposures in a very gradual manner; by starting with the easier situations, you can ease yourself into the treatment and build confidence in your ability to tackle harder things. By going step-by-step, it will help make the harder things seem less overwhelming, and you’ll have a great toolkit to fight OCD by the time we get to the top of your hierarchy. If anything ever seems to hard, just remember that we can always break things down into smaller components (e.g., a three-step checking ritual can be addressed one step at a time).”

As stated before, each exposure can have a number of iterations in order to titrate the difficulty to the child’s current ability. It is particularly helpful to break the exposure down into several components if the child has an elaborate ritual or has difficulty getting started with a hierarchy item. For instance, a child that has an extensive “just right” ritual may need to spin four times, tap the Table 11.3 times with their left hand, then three times with their right hand. Exposures may start with just the spinning part of the compulsion, gradually adding on the other parts of the ritual. In another example, a child with repetitive wiping compulsions that take up 2 hours at a time may be asked to decrease the wiping by 15-minute increments at first, rather than attempt to eliminate the 2-hour compulsion all at once. It is important to keep in mind that the ultimate goal is to eradicate the rituals completely, but sometimes it is necessary to decrease the supports gradually in order to

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TABLE 11.3 Examples of typical exposures for various obsessive-compulsive disorder (OCD) symptom subtypes. Exposurea

Symptom Contamination Fear of touching things in public spaces

• Touching commonly used surfaces (e.g., countertops, pens at banks, doorknobs in communal places)

Cross-contamination

• Coming into contact with a “dirty” surface and touching personal items afterward

Fear of contaminated food

• Eating food that’s been dropped on the floor

Harm/aggressive Fear of hurting others with sharp objects Fear that harm will come to others

Scrupulosity/religious Fear of offending God

• Writing detailed scripts about the ways in which harm will come to others and reciting them aloud • Allowing loved ones to separate from patient and not engage in reassuranceseeking • Writing and reading aloud passages praising the devil • Telling outright lies to strangers

Morality concerns Sexual Fear of being homosexual

Fears of sexually abusing others

Checking Excessive checking of stovetops

Checking items in bag

• Holding a pair of open scissors on the therapist’s wrist

• Looking at provocative pictures of the same sex; identifying attractive components about them • Purposely being around others in close proximity; attend more “vulnerable” locations (e.g., locker rooms, swimming pools) • Leaving the house without checking the stovetop; reciting that the house will burn down when leaving • Throwing items into the bag haphazardly and not checking what is in there the next day • Having others pack the bag for them without the patient’s involvement (Continued)

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(Continued) Exposurea

Symptom Symmetry/order Evening up clothing

• Pull one sock much higher than the other • Have the patient wear a glove on one hand but not the other • Place items askew and haphazardly, with no structure or order

Symmetry with items Counting Needing to count to a certain number Repeating Rereading/rewriting

• Count to a different number • Do not count at all when doing a task • Read through a passage only once within a certain time limit • Complete a page of homework without erasing, crossing out, or rewriting

General repeating rituals (e.g., in and out of doorways, up and down from chair)

• Walking through doorway one time and not going back through • Sitting down on a chair (without getting back up again) for 30 minutes (and gradually extending time)

a

Each exposure should be done in conjunction with response prevention (i.e., withholding the related compulsion). For instance, contamination exposures should be completed without allowing the patient to engage in decontamination rituals (e.g., handwashing, sanitizing, wiping, etc.).

facilitate success and augment compliance. For a brief list of typical exposures for various symptom subtypes, please see Table 11.3. In a related vein, exposures can be conducted via either imaginal methods or in vivo. Imaginal exposures consist of having the child imagine what their feared situation would be like in the utmost detail, as if someone was narrating a movie frame by frame. Sensory details should be included generously (e.g., sights, smells, temperature, sounds, etc.), as imaginal exposures should really allow the child to immerse themselves into the situation, as if it were truly playing out in real time. Imaginal exposures are particularly helpful for exposures that cannot be realistically completed in vivo, such as envisioning themselves in hell (for religious OCD symptoms) or picturing their house in flames because they did not check the stove enough times. Imaginal exposures can also be helpful for children that are having a particularly hard time jumping into in vivo exposures, serving as a stepping stone to completing the exposures in person. In general, in vivo exposures are preferred as the primary method, as the child and family get hands-on, real-life experience with immersing themselves in the situations and practicing the skills in real time.

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It is important to note that exposures should be conducted repeatedly. For example, if a child with over-responsibility concerns only tries not to text their caregiver one time (e.g., in order to prevent them from getting into a car accident), the child is not likely to be successful in resisting these compulsions without subsequent practices. Indeed, the child would not have had enough opportunities to see what really happens when they do not engage in the compulsion, which also disallows them from practicing how to tolerate uncertainty. Tolerating uncertainty is a particularly difficult task for patients with OCD, as many of the compulsions are purposed to reduce the uncertainty in some way (e.g., washing hands to decrease possibility of germs making them sick, tapping the table a certain amount of times to decrease the possibility that the caregivers may get into a car accident). However, given the reality that life is full of uncertainties (i.e., who knows what will really happen tomorrow?), the excessive engagement in rituals becomes problematic and interfering, so exposures will help youth learn how to tolerate distress in the face of uncertainties. Additionally, it is important to practice exposures in multiple contexts, in order to generalize practices. For instance, if a child with contamination fears only practices touching the doorknob in the therapist’s office, they likely will not learn to generalize these gains to other situations (e.g., doorknobs at school). This highlights the importance of context and out-of-session practices, in order to augment the number of practices/exposures and to generalize the contexts in which learning is occurring. When conducting exposures, it is imperative not to reassure the child about their fears during exposures. It may feel counterintuitive to not tell the child that “it is okay” and “nothing bad will happen.” However, reassurance will only serve to feed into the child’s fears; after all, if there is nothing to be afraid of, why would we need to reassure them? More importantly, one of the main goals of exposures is to violate expectancies, not necessarily to decrease their anxiety during the task (McGuire & Storch, 2019). In order to accomplish this, the child should be asked what they believe will happen prior to completing the exposure (e.g., “The house will burn down if I don’t check the stove 5 times”), complete the exposure (e.g., leaving the house without checking the burners on the stove), and then process with the therapist/caregiver what actually happened after the exposure (e.g., “The house did not burn down, even though I did not check the stove 5 times”). By doing exposures in this manner, this will allow for the maximal violation of expectations. Instead of providing reassurance about the OCD-related fears, caregivers and clinicians alike can support the child by commending the child’s efforts and sharing their confidence in the child’s ability to complete the exposure. Specifically, praising the child for attempting the

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exposure (e.g., “Great job being brave!”) will reward the child’s efforts in fighting back against their OCD, showing a sense of unity in treatment. When children are struggling with a particularly difficult exposure, sharing your confidence with their ability to complete it can help them build their own confidence in their ability to do it (e.g., “You’ve worked so hard and have done great with your other exposures, I know you can do this!”). Again, it is important to note that all of these types of supportive dialogue are directed at the child’s efforts and ability to do the tasks, not related to reassurance about OCD-specific fears. Additionally, children should not be distracted from the task at hand when doing exposures; this will help ensure that the child is directly confronting the feared trigger, rather than engaging in experiential avoidance (Abramowitz, Lackey, & Wheaton, 2009). It can be difficult to ask the child to focus on what is causing them distress, causing some well-meaning clinicians and caregivers to encourage the child to watch a TV show or engage in other activities whenever an OCD-related thought arises. However, by engaging in distraction whenever distress occurs, the child is functionally avoiding the OCD thought. Instead of facing the discomfort and learning from it, the child evades these triggers and is prevented from learning more adaptive ways of coping with the distress. Consequently, families should be explicitly advised to have the child focus on the exposure task in order to achieve the maximal benefit and circumvent therapy-interfering behaviors, like distraction. The following dialogue illustrates how to keep a child focused on the exposure at hand, particularly if they are prone to purposeful distraction:

“Therapist

Billy, I notice that you’re looking away from your hands while touching the toilet. What’s going through your mind right now?

Billy

I really don’t want to look at my hand, because I’m just going to think about all the germs that are crawling on it right now.

Therapist

Right, the germs are scary for you and they make it hard for you to focus. Based on what we discussed about fully confronting our fears and not avoiding them, why don’t we try to get our attention back on it? Can you look at the bottom of the toilet and tell me what you think?

Billy

It’s dusty and dirty, and there are germs on there.

Therapist

Good job focusing on the toilet—now move your eyes up to where your hand is and describe for me what you see and what you’re thinking.

Billy

My hand is touching this gross toilet seat and now all the germs are crawling over it! It’s making me feel really uncomfortable.

Therapist

You’re doing a great job focusing—keep up the brave work and let’s try to stick with it as long as we can. Can you continue to look at your hand and describe to me what’s going on?”

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Relapse prevention Once treatment has progressed up the fear hierarchy and the most problematic and difficult symptoms have been addressed, treatment typically decreases in frequency and intensity in order to match the child’s clinical presentation. Indeed, the child should be resuming more developmentally appropriate functioning toward the end of treatment (e.g., returning to school, seeing friends socially), which is a good indication that treatment will be concluding in the near future. The last few sessions should be dedicated to reviewing skills learned thus far and relapse prevention. In relapse prevention, families are instructed about what to look out for in case of worsening of symptoms, such as an increase in frequency, intensity, distress, and impairment related to OCD. Families are encouraged to take the skills that were acquired thus far in treatment and use them during potential resurgences of symptoms in the future. As OCD symptoms often wax and wane, it is not uncommon for some symptoms (or new symptoms) to reemerge in the future, especially in the instance of partial treatment response. The child is reminded to confront these uncomfortable situations in a systematic manner, refraining from engaging in any related compulsions whenever possible. Caregivers are expected to continue their integral role of supporting the child and facilitating the continuation of exposures as needed. Booster sessions can also be offered to families (typically once a month at first, then with longer breaks), especially for children that remain symptomatic or for those that would benefit from a refresher of ERP-related skills. Finally, if it has not been done already, the family should be commended and rewarded for their bravery and efforts in treatment. It can be enlightening to review the original fear hierarchy and see what has been accomplished over the course of therapy, reinforcing the hard work and importance of continued practices to maintain these gains.

Factors complicating exposure therapy for obsessive-compulsive disorder As is true when treating child psychopathology in general, there are myriad factors that may complicate the treatment for childhood OCD. Furthermore, given the unique and complex phenomenology of OCD, there are issues specific to the treatment of OCD. This section addresses common child and family characteristics that may arise in treatment, with discussions of how to handle these emergent difficulties.

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Insight and motivation The child’s level of insight may present as a challenge if s/he does not recognize the OCD symptoms as problematic. Indeed, this is particularly true for younger children who may not have the developmental capacity to realize the impact of the disorder (or that it is a disorder at all), lacking the cognitive maturity or independence to fully understand it. In these cases, a reward system can be very helpful in incentivizing a child to participate in treatment, even if they do not want to engage in the therapeutic tasks. A structured reward system should be completed in collaboration with the family in order to develop a system that everyone can agree upon. The rewards should be incentivizing enough for the child to want to engage in treatment, but the rewards should also be something that the parents are willing to dole out with relative frequency and are not particularly excessive (e.g., it is unrealistic to promise a trip to an amusement park every time an exposure is completed). For younger children, more frequent, tangible rewards may be more effective (e.g., extra screen time, little trinkets). For older adolescents, a point system (or token economy) contributing to bigger prizes (e.g., movie tickets, new console game) are more likely to be effective. When the problem is directed more toward low motivation, there are various approaches that can be employed to enhance engagement. Turning exposures into a game can be very effective for engaging children, as it will feel more fun and less like homework that they have to complete. For instance, contamination exposures can turn into scavenger hunts where the child has to find certain items hidden in different “dirty” areas, resulting in a grand prize if they are able to find them all. Exposures can also be treated as little scientific experiments where the child is a scientist and they are trying to test out different hypotheses. For instance, what would actually happen if I only touched the light switch once, rather than seven times? Again, a values-based approach can be helpful in these situations, in which the child recounts how treatment may help them reach their goals. Indeed, the clinician can highlight the times when the youth mentioned that they were struggling with something due to the OCD (e.g., making homework take longer to complete, getting in the way with friends), framing treatment as a way to help decrease OCD-related burden. Having the child list out potential ways that treatment can benefit them (rather than telling them how it may affect them) can also enhance their buy-in into treatment. Indeed, aspects of motivational interviewing have been shown to be helpful for improving outcomes in pediatric OCD (Merlo et al., 2010).

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Family accommodation Family accommodation is a salient phenomenon in childhood OCD, occurring in the majority of families, frequently on a daily basis (Peris et al., 2008; Stewart, Beresin, et al., 2008; Storch et al., 2007). These behaviors are characterized by a family member’s involvement in the child’s OCD symptoms, typically by participating in the child’s compulsions or modifying their routine in some way due to the OCD (Calvocoressi et al., 1995). Family accommodation may present in myriad ways, such as facilitating avoidance, providing excessive reassurance, and changing family schedules to accommodate time spent on compulsions. Families typically provide accommodation with positive intentions, hoping to assuage the child’s anxiety and reduce the time occupied by compulsions (Calvocoressi et al., 1999; Lewin, 2014; Storch, Bjo¨rgvinsson, et al., 2010). It is also normalized because caregivers typically want to prevent their child from experiencing distress, which is why many parents accommodate. However, these behaviors operate contrary to the principles of exposure therapy; by giving into the child’s OCD symptoms, it perpetuates the negative reinforcement cycle by disallowing the child from facing their feared situations and learning more adaptive ways to cope with the distress. Therefore the child is unable to learn that their feared outcome is unlikely to happen, or at the very least learn that they are able to tolerate the consequent distress (Abramowitz, 2013; Abramowitz & Arch, 2014). Consequently, families are discouraged from accommodating, and any existing types of accommodation should be added to the fear hierarchy with the ultimate goal of gradually eliminating these maladaptive behaviors.

Comorbid psychopathology Children with OCD often present with comorbid diagnoses, which can prove problematic if the comorbid psychopathology starts to interfere with the typical course of ERP. Indeed, youth presenting with externalizing symptoms (Garcia et al., 2010; Torp et al., 2015), especially attention deficit/hyperactivity disorder (Farrell, Waters, Milliner, & Ollendick, 2012) and disruptive behavior disorder (Storch et al., 2008), tend to demonstrate poorer treatment response. Behavioral parent training principles employed in conjunction with typical ERP can be helpful with these comorbidities, particularly if the family is having difficulties with setting limits, providing structure, and establishing consistent expectations (Lebowitz, 2013; Sukhodolsky, Gorman, Scahill, Findley, & McGuire, 2013). For instance, techniques of planned ignoring (e.g., ignoring the child’s pleas to do their rituals with them), employing reward systems for desired behaviors (e.g., using a calm voice rather

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than throwing a temper tantrum), and labeled praise (e.g., “It was very brave of you to stop yourself from washing your hands—great job!”) will all be helpful for behavioral problems. If the attention and hyperactivity are difficult to manage with behavioral management principles, concurrent medication may be warranted in order to help the child focus on the exposure tasks at hand. Some internalizing symptoms (Torp et al., 2015), particularly major depressive disorder (Storch et al., 2008), have also been linked with attenuated response to ERP. Indeed, youth with comorbid depressive symptoms typically have more cognitive distortions and higher OCD symptom severity (Peris et al., 2010). If the depressive symptoms appear to be significantly interfering with the child’s ability to carry on with daily tasks (let alone exposures), depression-focused treatment may be indicated prior to conducting ERP; behavioral activation (e.g., scheduling pleasurable tasks) or interpersonal therapy (for depressive symptoms highly influenced by personal relationships) are both efficacious and well-validated treatments for child and adolescent depression. Otherwise, if the OCD symptoms appear to be the primary cause of the depression (i.e., secondary depression), then ERP can generally proceed as usual and the depressive symptoms often attenuate accordingly (Zitterl et al., 2000).

Surreptitious compulsions and therapy-interfering behaviors Subtle compulsions, especially mental rituals, can be easily overlooked in treatment. For instance, a child with religious obsessions may automatically recite, “Forgive me, God,” whenever they feel they have a blasphemous thought, which makes it very hard for the clinician and caregivers to know when these behaviors are happening. Alternatively, a child with contamination fears may do a very quick wipe on their pants as a decontamination ritual, which would be easily missed if the clinician was not looking at the child during that 1 second. Given that these are compulsions, they will undermine the purpose of exposures if the child engages in these behaviors while confronting their fears. In order to prevent this from happening, a thorough assessment and thoughtful construction of a detailed fear hierarchy at the outset can help capture these behaviors and place the clinician/family on the lookout during exposures. Awareness-building exercises with the child may also be helpful, particularly if these behaviors have been ingrained into their routine and come almost automatically after an obsession; completing purposeful logs of the frequency and situations in which the compulsions come up would be helpful to assist with awareness training. A sample dialogue regarding

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thoughtful communication of how to deal with subtle compulsions is included subsequently:

“Therapist

I noticed that you have been quickly brushing your hands on your pants after touching the trash can these last couple of times. Did you catch yourself doing it too, or did you not notice yourself doing that?

Billy

Oh no, I had no idea I was doing that! I have been doing all these wiping rituals for so long that I can’t even keep track of them sometimes.

Therapist

You’re right, it can be quite tough to break a habit that has been going on for a while, especially if it seems to just be routine now! What do you say we come up with a system to help you catch yourself when you’re doing it? Would you be okay with a hand signal from me or your parent, whenever we notice?

Billy

Oh, I think raising a finger when it happens will get my attention. We can try that.”

“White-knuckling” through exposures is also a common phenomenon that occurs in ERP (Herren & Berryhill, 2018), in which the child hurriedly powers through an exposure in anticipation of completing the exposure. By doing so, the child reinforces the OCD cycle by focusing on the need to escape uncomfortable situations. White-knuckling is typically observed through gritting of the teeth, tensing of the body, clenched fists, and statements of being “fine,” despite apparent signs of distress. With these indications, it is important to slow the exposure down and ask the child to fully confront the feared situation. Children can be gently oriented to notice the somatic sensations they experience while white-knuckling through an exposure, drawing attention to the behaviors that should be addressed. Varying (unexpected) time limits on the exposures can help as well (to prevent the child from counting down the time until the exposure is done), and temporarily reducing the intensity/duration of the exposure can assist with allowing the child to be more present in the exposure as well. These techniques will ensure that the child is not simply going through the motions, but is instead completing the exposures as intended, allowing them to maximally benefit from treatment.

Conclusion Pediatric OCD is a heterogeneous psychiatric disorder that imposes significant interference in various domains of life. ERP is an efficacious, front-line behavioral treatment for pediatric OCD, primarily focused on

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having the child confront their feared situations and refraining from engaging in compulsions. Treatment is conducted in a systematic manner, employing a time-limited, goal-oriented approach. Therapy is personalized in content, duration, and intensity, but all youth work to learn how to face OCD-related triggers without engaging in compulsions. Through this process, youth are able to form more realistic appraisals of the situation, decrease dependence on compulsions in reducing distress, and acquire more adaptive coping skills. Together, the child, clinician, and family work to collaboratively foster a supportive environment in helping the child overcome OCD.

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Garcia, A. M., Sapyta, J. J., Moore, P. S., Freeman, J. B., Franklin, M. E., March, J. S., & Foa, E. B. (2010). Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 1024 1033. Geller, D. A. (2006). Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatric Clinics of North America, 29(2), 353 370. Available from https://doi. org/10.1016/j.psc.2006.02.012. Herren, J., & Berryhill, J. (2018). Working with young children with OCD. In E. A. Storch, J. F. McGuire, & D. McKay (Eds.), The clinician’s guide to cognitive-behavioral therapy for childhood obsessive-compulsive disorder (pp. 289 308). San Diego, CA: Elsevier, Inc. Hu, X. Z., Lipsky, R. H., Zhu, G., Akhtar, L. A., Taubman, J., Greenberg, B. D., . . . Goldman, D. (2006). Serotonin transporter promoter gain-of-function genotypes are linked to obsessive-compulsive disorder. American Journal of Human Genetics, 78(5), 815 826. Available from https://doi.org/10.1086/503850. International Obsessive Compulsive Disorder Foundation Genetics Collaborative (IOCDFGC), & OCD Collaborative Genetics Association Studies (OCGAS). (2017). Revealing the complex genetic architecture of obsessive-compulsive disorder using meta-analysis. Molecular Psychiatry, 23(5), 1181 1188. Available from https://doi.org/10.1038/ mp.2017.154. Lebowitz, E. R. (2013). Parent-based treatment for childhood and adolescent OCD. Journal of Obsessive-Compulsive and Related Disorders, 2(4), 425 431. Available from https://doi. org/10.1016/j.jocrd.2013.08.004. Lewin, A. B. (2014). Tractable impediments to cognitive behavioral therapy for pediatric obsessive compulsive disorder. In D. McKay, & E. A. Storch (Eds.), Obsessive compulsive disorder and its spectrum: A lifespan approach (pp. 81 96). American Psychological Association Press. Lewin, A. B., & Piacentini, J. (2009). Obsessive-compulsive disorder in children. In (9th ed. B. J. Sadock, V. A. Sadock, & P. Ruiz (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (Vol. 2Philadelphia, PA: Lippincott Williams & Wilkins. Mattheisen, M., Samuels, J. F., Wang, Y., Greenberg, B. D., Fyer, A. J., McCracken, J. T., . . . Nestadt, G. (2014). Genome-wide association study in obsessive-compulsive disorder: Results from the OCGAS. Molecular Psychiatry, 20(3), 337 344. Available from https:// doi.org/10.1038/mp.2014.43. McGuire, J. F., Piacentini, J., Lewin, A. B., Brennan, E. A., Murphy, T. K., & Storch, E. A. (2015). A meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: Moderators of treatment efficacy, response, and remission. Depression and Anxiety, 32(8), 580 593. Available from https://doi.org/10.1002/ da.22389. McGuire, J. F., & Storch, E. A. (2019). An inhibitory learning approach to cognitivebehavioral therapy for children and adolescents. Cognitive and Behavioral Practice, 26(1), 214 224. Available from https://doi.org/10.1016/j.cbpra.2017.12.003. McGuire, J. F., Wu, M. S., Choy, C., & Piacentini, J. C. (2018). Exposures in cognitive behavior therapy for pediatric obsessive-compulsive disorder: Addressing common clinician concerns. Journal of Child Psychology and Psychiatry, 59(6), 714 716. Merlo, L. J., Storch, E. A., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., Goodman, W. K., & Geffken, G. R. (2010). Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive compulsive disorder: A preliminary study. Cognitive Behaviour Therapy, 39(1), 24 27. Modell, J. G., Mountz, J. M., Curtis, G. C., & Greden, J. F. (1989). Neurophysiologic dysfunction in basal ganglia/limbic striatal and thalamocortical circuits as a pathogenetic mechanism of obsessive-compulsive disorder. Journal of Neuropsychiatry and Clinical Neurosciences, 1(1), 27 36.

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C H A P T E R

12 Using exposure with young children Amita D. Jassi and Z. Kindynis National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom

Cognitive behavior therapy (CBT) is a well-established and evidencebased treatment for child and adolescent anxiety (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Within any CBT framework for anxiety, exposure therapy is an essential element (Kazdin & Weisz, 1998). Therapists implementing exposure techniques aim to support young people to approach anxiety-provoking situations, focus on the trigger and resist attempts to reduce anxiety (Benito & Walther, 2015). There are two frameworks for understanding the mechanisms behind how exposure works: one is inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014; McGuire & Storch, 2019) and the other is habituation (Benito & Walther, 2015; Foa & Kozak, 1986). Ultimately, the goal of exposure is to promote distress tolerance (inhibitory learning) and allow reduction of anxiety over time (habituation). Despite strong evidence for the effectiveness of CBT with exposure for various anxiety disorders in young people (Freeman et al., 2014; Kendall et al., 2005), there is significantly less literature for children aged 7 years and below (Rudy, Zavrou, Johnco, Storch, & Lewin, 2017). Some evidence suggests that younger children may have difficulties accessing and engaging with CBT more generally (Grave & Blissett, 2004) and may not respond as well as their older counterparts (Durlak, Fuhrman, & Lampman, 1991; Weisz, Weisz, Han, Granger, & Morton, 1995). However, it has been argued that tailoring treatment to the developmental level of the child enables good outcomes (Freeman et al.,

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2014; Ollendick, Grills, & King, 2001). Considering the high prevalence rates of anxiety disorders in young children (Rudy et al., 2017), together with the identified need to provide early intervention for children with anxiety disorders (Hirshfeld-Becker & Biedermann, 2002; Stewart et al., 2004), it seems pertinent to explore how the well-established intervention of exposure-based therapy can best be provided for this age group. This chapter draws on the existing literature and clinical experience to explore the adaptations necessary to facilitate exposure therapy in young children. The chapter is for clinicians with limited experience of using exposure with this group but have a working knowledge of exposure therapy in general. We start the chapter by considering the broad modifications needed for younger children and then discuss how to incorporate these for different aspects of treatment. We use two case examples, Danny and Parveen, to illustrate exposure work with this age group. Danny is an 8-year-old boy who has obsessive-compulsive disorder (OCD). His compulsions included tapping, counting, and evening up owing to a “just right” obsession. Although he did not have to complete compulsions at school, he engaged in compulsions almost constantly when he was at home. He had started to notice his “evening up” compulsions interfered with his ability to play soccer, as he had to try to ensure both his feet touched the ball an equal number of times. These compulsions caused him significant distress, and as a result, he often became angry and shouted when he felt unable to perform a compulsion to completion. As Danny struggled to articulate why he is performed such routines, his parents suggested that he was in control of his routines and was tapping objects repeatedly to “annoy them”. They were worried about his recent angry outbursts and believed that this was a reflection of him becoming “naughty”. Parveen is a 6-year-old girl who was scared of dogs. Her fear started a year ago after her grandmother’s new dog chased her through a park and she thought he would bite her. Following this, she started to get upset and anxious when going to the park, her grandmother’s home and other places due to fear of seeing a dog. Parveen would cry and scream if she thought she would come into contact with one. Her mother, Zara, brought her to therapy as this fear was causing Parveen a great deal of distress and restricted where the family could go. They were unable to visit her grandmother who Zara, as a single parent, relied on for childcare. Zara felt very guilty about Parveen developing this fear; she was in the park when the dog chased Parveen and felt it was her fault for not recognizing she needed her help. She believed she was a bad mother and felt judged by Parveen’s grandmother as she said that Zara should stop accommodating Parveen’s phobia and make her come to her house. However, Zara did not want Parveen to be distressed as she believed this could “damage” and traumatize her further.

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Overview of modifications to exposure for young children Throughout the treatment components, clinicians will notice several overarching themes regarding the suggested modifications for working with younger children. These themes include: (1) developmental adaptations, (2) family work, (3) play-based approaches, and (4) contingency management techniques. First, a consideration of the child’s developmental level is necessary to ensure appropriate adaptations to all treatment components. Gauging the developmental level of the child will be essential to inform how best to establish rapport, plan sessions, and tailor the content of the therapy sessions. Therapists can do this when having a simple conversation with the child; this can help to gauge the child’s receptive and expressive language skills; how long they can stay engaged in the conversation can give an idea of their attention and concentration; and asking them questions such as what they did last week, can help assess their memory capacity. Younger children have limited attention span, memory capacity, and general mental organizational ability (Crick & Dodge, 1994; Russell & van den Broek, 1988). Therefore it may be pertinent to either plan shorter sessions, or to schedule breaks during sessions for optimal learning. Furthermore, the child may require more repetition and practice of skills during sessions in order to consolidate their learning. Guidance from parents can help inform decisions regarding which approaches may be best to optimize learning for their child (e.g., shorter sessions, scheduled breaks, etc.). Family involvement is an integral part of treatment with young children, and therapists have to engage and build rapport with the child and parent in equal measure to ensure success. There is emerging evidence to suggest that younger children benefit more than older children from the involvement of their families in treatment (Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, & Spence, 1998). As a young child’s developmental level may limit their understanding of what is presented in therapy, parental understanding is critical for treatment success (Herren & Berryhill, 2018). Parents can be considered the experts on their child, and represent an invaluable asset both as an informant and co-therapist. Furthermore, anxiety disorders in younger children are likely to affect the whole family unit, whether this is observed in familial anxiety (e.g., parents with anxiety, worries about child behavior) and/or family accommodation (e.g., providing special accommodations and avoidance of feared stimuli; Zavrou, Rudy, Johnco, Storch, & Lewin, 2018). Given the importance of including families in treatment, therapists should evaluate and address beliefs that parents may bring into sessions (e.g. beliefs about anxiety, perceptions about the origins of a child’s behavior). These may be achieved by either tailoring session materials or conducting separate parent sessions at the start of treatment.

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When working with young children, it is important to remember that the more fun and interesting a therapy session, the more likely the child will engage and participate (Drewes, 2009). One approach might include integrating exposure tasks into a scavenger hunt or having 10 minutes of play directed by the child at the end of each successful session as a reward. Additionally, active learning in sessions is preferable (Bonwell & Eison, 1991) and results in greater learning (Woods, 2009). Active learning is experiential (e.g., scaring each other in session to identify symptoms of anxiety), whereas passive learning may entail information being shared with the child (e.g., showing the child a picture of a body with anxiety symptoms on it). Therefore to enhance engagement and learning in sessions with young children, treatment should incorporate play-based and behaviorally active learning, while tailoring content to the idiosyncratic interests of the child. Finally, many young children have limited insight into the necessity for change and/or the rationale for exposure work (Langley, Bergman, & Piacentini, 2002). Therefore contingency management can provide important motivation for engagement. Two approaches to contingency management for young children include praise and rewards. This chapter focuses on the different elements of exposure therapy, from psycho-education to facilitating exposure tasks, discussing how these components can be modified for younger children using the themes mentioned above.

Psycho-education and developing a formulation Psycho-education is a fundamental element of treatment that provides the child and family with an understanding of their difficulties, and a rationale for exposure work. Typically, this component of treatment covers psycho-education on anxiety including the physical anxiety symptoms, the fight or flight response, and habituation. In terms of a shared formulation, the child and family need to understand the cycle of thoughts, feelings, and behaviors and how this cycle can be broken with exposure therapy, in order to form a united team to fight fears together (see Chapter 12 for a more detailed discussion of psychoeducation for exposures). As a young child may not be able to access psycho-education fully, it is crucial that parents have a full and clear appreciation of these concepts. Indeed, a parent’s ability to understand the concept of exposure and to encourage their children to expose themselves to the feared situation is critical to treatment success (Herren & Berryhill, 2018). There is emerging evidence to support that treatment delivered via parents alone is effective for anxiety disorders in young children (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010; Rudy et al., 2017), III. Developmental considerations

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which adds weight to the importance of parents being fully involved. It is useful to complete a separate psycho-education session with caregivers at the outset of treatment to establish rapport, ensure that caregivers accurately understand and “buy in” to the exposure model, address any unhelpful beliefs that could impact on treatment, and to allow the clinician to establish the caregiver’s role as an actively involved co-therapist. From the outset of treatment, it is helpful to externalize the anxiety disorder; a tool derived from Narrative Therapy (Freeman, Epston, & Lobovits, 1997). Giving the disorder a name and identity removes the blame from the child and allows a family to unite in fighting against the externalized condition. Moreover, it can help the child recognize the anxiety disorder as something separate from their own identity. For example, Danny considered names such as “Bully” or “Mr Worry” for his OCD before deciding on “Grumpalump.” Danny drew a picture of Grumpalump and every session this picture was put on the wall to remind his family to externalize Danny’s difficulties and use the name Grumpalump.

Danny’s picture of OCD called “Grumpalump”

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The family and the child are encouraged to use externalizing language wherever possible, and the clinician should aim to model this throughout sessions. Externalizing the condition in this way allows for a continued narrative that can help the child and family throughout treatment. For example, asking “What does the bully tell you will happen if you don’t do that?” can support children with accessing their worries, and continuing a narrative of aiming to “run OCD off my land” (March & Mulle, 1998), “squash Mr Worry,” “fight back against Grumpalump,” can be a helpful reminder of the rationale for conducting exposures. If a child does not want to name their disorder, it is encouraged that the clinician uses externalizing language by naming the disorder itself (e.g., “OCD,” or “anxiety”). In terms of delivering psycho-education to the child, therapists should be aware that the child’s cognitive capacities may result in limited understanding of some concepts. This may be particularly relevant if the concepts are abstract, hypothetical scenarios, or theoretical aspects of the exposure model (Drewes, 2009). Generally speaking, psychoeducation for a younger audience should aim to include less complex and verbally mediated techniques, and integrate more play-based, behaviorally active learning (DiGiuseppe, 1989) such as concrete picture and story-based tasks (Grave & Blissett, 2004). Puppets and cartoons can also be used to deliver didactic information in a more engaging, understandable way (Felix, Bond, & Shelby, 2006). For example, in Danny’s session the therapist explained how OCD is experienced in the following way:

Therapist

Danny, I would like you to pick two puppets out of this box, one is going to be you and one is Grumpalump. You can ask Mummy and Daddy to help you if you want.

Danny

OK

Therapist

Right, who is going to be you and who is going to be Grumpalump?

Danny

Mummy can be me and I will be Grumpalump

Therapist

Brilliant—well done. Now Danny is about to play soccer and he is getting ready to score a goal and look whose coming, its Grumpalump—show me what happens? What does he say?

Danny

Hello my name is Grumpalump and I am scary and you have to listen to me. Now tap your feet on the ball until I say it’s ok!

Therapist

Oh no, Grumpalump is so annoying, how does Danny feel Mummy?

Mum

Go away, I hate you Grumpalump, stop scaring me, I don’t want to listen

Therapist

Show me what Grumpalump does. What does he say?

Danny

I am not stopping until you listen to me Danny—now tap, tap, tap!

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Younger children are found to have a limited ability to recognize, understand, and differentiate emotional states (Izard, 1994). There is also evidence that capacity for introspection is not fully developed until adolescence (Harter, 1990); therefore young children are likely to have difficulties identifying and articulating their thoughts and emotions. This is exemplified by young children with OCD often displaying compulsions without identifying obsessions (Freeman et al., 2012). As such, it may be worth focusing on thought and emotion identification, with the focus being on anxiety. Again, this can be facilitated creatively using cartoon stories with blank thought bubbles, or by watching videos to help children recognize and report the emotion of anxiety. These can be selected according to the child’s interests; some nice examples of fear and anxiety can be found in various shows including Disney’s Inside Out, Monsters Inc., Harry Potter, and Mickey Mouse cartoons. Alternatively, physiological anxiety symptoms can be demonstrated by using a child’s toy (e.g., breathing quickly, shaking, etc.), or by playing games involving making each other jump and identifying anxiety symptoms. For example, Parveen and Zara were given homework to watch the Disney film Inside Out and were asked to focus on the character of “Fear” in the film. They were asked to focus on which situations Fear appeared in, and how he influenced the main character’s thoughts and behavior. Parveen drew the character and this was used in sessions to communicate when she felt scared. The other characters were used from the film to think about the differences between the emotions. Some young children may have limited emotion recognition and may struggle to identify or recognize anxiety. In such instances, therapists may feel they are unable to proceed with therapy; however, this is not necessarily the case. Even if the child struggles with this aspect of treatment, therapists must ensure parents understand what anxiety symptoms to look out for and what symptoms they recognize in their child. Therapists need to hold in mind when coming onto implementing exposure tasks later in therapy that they may not be able to gauge what task to do based on the child’s anxiety ratings but may have to reframe this into how easy or difficult a task or think about tasks being done based on ratings made by parents on how anxious they think the child will be based on their experience. If a child is able to recognize thoughts and emotions and once they feel more confident in doing so, it is helpful to map out the anxiety cycle and how thoughts, feelings, and behaviors are interlinked. This can be an abstract concept for young children to grasp, and so kinesthetic games, manipulative materials, or physical activities can assist with illustrating this cycle (Drewes, 2009). For Parveen and Zara, the therapist placed three large pieces of paper labeled thoughts, “feelings,” and

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“behaviors” on the floor and they each stood on one. They shouted out the word on their piece paper, and then threw a ball to the next person. This started with “thoughts,” then “feelings,” and then “behaviors,” and repeated until Parveen understood the cyclical nature of how these related. As the session progressed, they started to substitute words for an example of a thought, feeling or behavior focusing on the characters from a scene from Inside Out. They placed pictures of the different emotion characters (Joy, Anger, Sadness, Disgust, and Fear) on the feelings paper and discussed what a person may think and how they would behave if that character was in charge. When discussing Fear, the therapist used Parveen’s fear of dogs as an example, and also asked Zara to share something she was scared of to normalize anxiety. Parveen struggled to describe thoughts at times, but was able to understand the relationship between her feelings and behavior clearly. Zara became clear on this cycle and recognized that Parveen avoiding and running away from dogs was reinforcing her fear as she was not challenging the thought that they may bite her. Once a cycle has been mapped out, it is important to help the young person and parents understand that exposure work breaks this maintenance cycle, by preventing the behavioral response, and thereby allowing anxiety to habituate. This notion requires the understanding of advanced concepts, which may be beyond the cognitive capacity of young children. However, the key principles can still be considered creatively using a variety of metaphors, depending on the developmental level of the child. For example, using narrative techniques, the child may be able to articulate that when they do what “the bully” wants, the bully gets bigger and stronger. However, when the child ignores the bully, the bully gets angry for a little bit but then goes away. They may also be able to understand that if they keep ignoring the bully, he will get bored and stop bullying them. This illustrates that facing the fear (and ignoring “the bully”) repeatedly is the way to fight anxiety and get better in the long term. Danny was able to relate to the concept of soccer and so the therapist used an example of Team Danny and Team Grumpalump. Danny understood that every time Grumpalump succeeded in making Danny complete a compulsion, Team Grumpalump scored a goal against Team Danny, and got stronger. Danny was able to see that the way for Team Danny to score goals against Team Grumpalump was to not do what Grumpalump wanted him to. To support learning about habituation, you can use examples with the child and family such as swimming in a cold pool. Over time, the body gets used (or habituates) to the temperature. Another example might be going on a ride at a theme park, which may be scary the first time but it gets easier the more times they try the ride. Examples about how to practice with a sport or hobby help them get better, also illustrate the necessity for repetition and practice to facilitate improvement. If clinically indicated, and if parents have experience of facing anxietyprovoking situations, it can be helpful to ask parents to share examples

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of when they have faced their fears and their anxiety habituated. Not only can this bolster confidence in the child, who will trust what their parents say, but it helps the parent to relate their experiences to the exposure process, buy into the approach, and challenge some of their beliefs about anxiety being dangerous or something to be avoided. Young children are highly varied developmentally and will not all benefit from the exact same application of treatment strategies (Kendall et al., 2005). Therefore it will be important to idiosyncratically tailor psycho-education to the child’s developmental level and interests. Furthermore, it is not always necessary to cover every component in close detail for young children, and some aspects may be condensed while still achieving an understanding of the rationale for exposure work. It is, however, vital that the parents understand the key concepts in this part of the therapy, so they are prepared to take on the role of co-therapist. With this in mind, therapists may need to explain to parents the importance of them being involved in therapy. Below is a conversation that took place in separate parent session with Zara:

Therapist

Given what we have covered so far, how do you think Parveen will overcome her fear of dogs?

Zara

Well she needs to confront them, step by step, and she will get used to it

Therapist

Great! What do you think will happen to her anxiety when she faces a dog?

Zara

She will be petrified, but you said she will calm down, her anxiety will come down

Therapist

Great stuff. Zara, I was interested in what you think your role will be in the tasks?

Zara

I guess I will be in session with her, bring her here and maybe I can arrange for my mother to bring her dog in

Therapist

That would be super helpful. I know therapy is really hard work and we have spoken about some of your fears about what will happen if Parveen gets anxious. We encourage families to help set up tasks and do tasks alongside their child, what do you think about that?

Zara

I’m really not sure; I just don’t want to stress her out

Therapist

I understand. What do you think are the reasons for asking parents to take an active role in tasks?

Zara

So Parveen can see I am in charge, can support her, put boundaries in and that I am not scared

Therapist

All great reasons. We also know you have to do a lot of the hard work outside of sessions as an hour a week is not enough. We find that if we coach parents through setting up and seeing tasks through, that can help them to support their child outside of sessions (Continued)

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(Continued) Zara

That makes sense

Therapist

Zara, I have picked up on some of the worries you still have about the effect of anxiety on Parveen. I know it’s really hard to see your child anxious but what do you remember about what we have learnt about anxiety?

Zara

It’s not harmful, it’s normal and it does not last

Therapist

Great! I know when we do these tasks both you and Parveen will be feeling anxious, so we have to hold in what we have learnt. Do you think it would be helpful for us to have a check in after tasks to see how you have felt about setting them up and what you have learnt about anxiety—both yours and Parveen’s?

Zara

That would be great.

Anxiety rating scale An anxiety rating scale provides a ruler by which the child can communicate their level of distress during and beyond exposure tasks. Typically, a scale from 0 to 10 is used. As discussed, young children can struggle to identify their emotions and may also have difficulties identifying the strength of these emotions (e.g., often reporting an “all-ornothing” experience of anxiety; Herren & Berryhill, 2018). Therefore a smaller range may help to simplify this process (Kendall et al., 2005). However, young children may struggle to extrapolate feelings to number ratings and so this scale is likely to require modification to include visual cues such as pictures, emojis, colors, or symbols. This is also a nice opportunity to incorporate the child’s interests, and to use playbased methods to creatively develop a personalized scale together. For example, Parveen created a papier-maˆche´ volcano as her scale, which allowed for a creative and engaging activity while still developing an understanding of levels of anxiety (e.g., from grass at the bottom to the top with lava spewing out). Parveen printed pictures of Fear from Disney film Inside Out in progressively larger sizes and placed them onto her volcano to represent different levels of her anxiety. Younger children may require lots of practice of using this scale with scenarios unrelated to their anxiety disorder, to consolidate their understanding of how to utilize it. This can also be facilitated in a fun, and concrete way. For example, a clinician may ask everyone to watch a scary video and use the scale to measure their anxiety.

Building a hierarchy Once the anxiety scale is established and the child and family feel confident with its use, this framework can be used to develop a fear

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hierarchy. The fear hierarchy provides an exposure treatment plan that identifies specific feared situations that the patient will gradually face and ranks these according to their anxiety scale (Abramowitz, Deacon, & Whiteside, 2011). Building a fear hierarchy requires an accurate assessment of what triggers a child’s anxiety. However, young children may struggle to generate specific situations that they are fearful of, owing to difficulties identifying emotions, poor insight into the impairment (Langley et al., 2002), and difficulties articulating the nature of their fears (Kendall et al., 2005). Therefore collating information from multiple informants (parents/caregivers, siblings, teachers, and observations) can aid in identifying scenarios to add to the hierarchy. Again, ensuring that this process is facilitated collaboratively and creatively according to the child’s developmental needs and interests will assist with maintaining engagement. Examples of this include the child drawing out pictures of their feared scenarios, cutting these out, and then fixing them onto their anxiety scale. For example, Parveen and Zara used the internet to find pictures of different dogs which stuck onto her volcano.

Parveen’s hierarchy using her volcano anxiety scale.

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Designing exposure tasks The first stage of designing an exposure task is to review the hierarchy to decide which step to take. Knowing where to start on the hierarchy is often the challenging part. For younger children, it is important to choose a step on the hierarchy that will provoke mild distress, but will give them the best chance of successfully completing the task to build their confidence. It is best to start too low rather than with something that is challenging and could put them off further tasks. With younger children the pace of moving up the hierarchy is slow and therapists may need to break each task down into smaller steps as they go along. For instance, Parveen’s hierarchy initially focused on different types of dogs but subsequently included additional steps regarding how close she would get to these dogs and situations where she may encounter dogs. In choosing a task, therapists have to strike a balance between what the parents, child, and therapist think should be the task. The way the tasks are chosen by the family and child is likely to be different. Therapists may be more likely to be aligned with the parents whose goal will be their child overcoming their anxiety difficulties and reducing the impact this has on their functioning. However, therapists must be aware this goal may not be shared by the child and therefore the emphasis when choosing a task may need to be changed. An important part of engaging young children in choosing a task is to think about the reward system to put in place. At this point in treatment, therapists have a sense of the young person’s interests, likes, and dislikes, as well as what the family is able to offer in terms of rewards. When designing a task, it is the reward rather than overcoming the fear that often is the driver behind the child choosing and engaging in tasks. Therapists may focus on what reward the child can get and then explaining how they can get it, rather than focusing on the task in itself or reviewing the hierarchy to choose a step. It may be helpful to have a hierarchy of rewards to engage young people to continually challenge themselves, to earn better rewards as they go along. For example, Danny was rewarded with a different number of “goals” for tasks of increasing difficulty; for each task, he had to pick how many goals he wanted to win and the therapist explained how he could earn them. He made a scoreboard to record the “goals” he had “scored against Grumpalump” and there were pre-agreed prizes depending on how many goals Danny could score. When thinking about rewards, it is important the family and child are clear about what they have to do to get the reward. Young children should get a reward for making attempts at the task, rather than successfully completing it, so it should be clearly set out exactly what that would look like. For example, Danny received a reward of playing soccer in

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the garden with his father for trying a task of resisting tapping, whether he was successful or not, but earnt extra time for completing the task. Rewards for younger children may range from getting stickers to earning tangible goods or a privilege (e.g., more time on the computer or screen time). However, for some children, it may be attention from their parents or quality time with them that serves as a reward. It is important to spend time thinking about the details of this with the family and child. Parental attention is something we will come back to when we discuss implementing exposure tasks. Younger children may need more immediate rewards after attempting tasks, and may struggle with delayed gratification and so it is clearly paired with the approach behavior which is then positively reinforced (Mischel & Metzner, 1962). Once a step on the hierarchy and the corresponding reward has been chosen, it is important that the child and family have a clear and specific plan for the task. The details of planning the task include what the exposure will involve (e.g., what is the feared stimuli, how long the young person needs to be exposed for, what the young person and parents have to do during the exposure, and when the task is finished). The goal of exposure is for them to face the anxiety-provoking stimuli to learn they can tolerate anxiety and that it does eventually reduce, therefore this needs to be held in mind when designing the task. It is important when designing a task to again keep it visual and use play. Therapists may find it helpful to draw, show videos, or use puppets to show what a task would look like and help the child understand what is expected of them. There has to be a balance between setting up the task clearly so the young person and family know what to do and expect, while initiating the task as soon as possible in session so as to reduce anticipatory anxiety. The role of the therapist is to support the young person to engage in the exposure task, so as well as using rewards, making the tasks fun, and engaging is important. Therapists can come up with creative ways to do so, such as making it into a game or setting up an exposure competition. Families have a wealth of information they can draw on seeing their child outside of the therapy setting, which needs to be utilized when designing tasks. However, there may be issues that could come up in the process such as some parents struggling to push their child due to their own anxiety or their expectations being too high for their child. If this happens and it interferes in the design of tasks, therapists may consider having a separate session with parents to explore these issues. This may allow parents to share what their concerns may be and facilitate a way forward as well as giving an opportunity to revisit the psycho-education to remind them of why the tasks are being implemented. For example, Zara had strong beliefs that anxiety would damage or

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traumatize Parveen. Psycho-education on anxiety started to shift some of these beliefs; however, these were activated when exposure work began. The therapist arranged a separate session with Zara to consider this in more detail and to support her in relating her own experiences of overcoming fears.

Implementing exposure Once the exposure task has been set up, the task needs to be implemented with modifications for a younger child, to support them to engage in the tasks. Therapists need to strike a balance between the two exposure frameworks (habituation and distress tolerance). Younger children may struggle to tolerate distress; therefore there may be an increased risk that others, both parents and therapists, will engage in behaviors aimed at reducing...”? Therapists must assess these behaviors to ensure they do not undermine the anxiety habituation process (Benito & Walther, 2015). Incorporation of strategies, such as therapist and parent praise, positive encouraging self-talk, rewards, and modeling distress tolerance can help make this model more acceptable (Herren & Berryhill, 2018). For families who find it hard not to give reassurance, they may need to be given alternative statements so they can offer support such as “What would Harry Potter do?” “You are really brave, you can do it” or “Remember you will get a token after this task.” These are statements that provide encouragement and support without directly addressing anything about the feared stimuli. These statements can also be used by the young person themselves as positive self-talk. They can make posters of the statements and put them up at home as visual reminders and have pictures taken of them engaging in exposure tasks as a reminder of their bravery for encouragement during therapy. It is important that any techniques introduced into the exposure tasks have a neutral effect on anxiety so as not to undermine the principles underlying exposure work; that is the child learning they can tolerate distress and that anxiety habituates (Benito & Walther, 2015). Earlier we touched on parent attention being a potential reward when completing tasks. If a functional analysis is completed and it is deemed that the child is getting attention for negative or anxious behavior, which then reinforces it, then this needs to be addressed in sessions. Parents may need a separate session to discuss how they manage this where they are encouraged to try not to give attention to the child when they are trying to avoid the feared stimuli or resisting exposure and to attend to any approach behaviors. Other contingency management strategies may need to be considered if there are challenging behaviors during treatment; this will be discussed at the end of the chapter.

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Therapists have to be vigilant to behaviors the child is engaging in when undertaking exposure to ensure they are fully engaging with the tasks (e.g., not distracting themselves or engaging in mental rituals). It is helpful to draw on what was included in psycho-education, including externalizing the fears, as a way to support young children through the process as well as reminding them of the reward they will get after the task. Younger children may find it helpful if tasks are modeled before they do it so they can repeat the task after they have seen it or for someone to do the task alongside them. This can help them feel they are not alone when they undertake exposures, but also makes it clear to them as to what is expected for them to do. It is useful to get parents to do this as this can facilitate them in undertaking tasks with their child for homework. Therapists have to be careful that the child does not begin to rely on tasks being modeled or having someone to do it with them, as this will reduce the generalizability of exposure tasks to real-life situations and can undermine their sense of self-efficacy and may inadvertently provide reassurance. It is therefore helpful to introduce modeling when the child is struggling to engage in the task as opposed to it being done for every task. With younger children, therapists need to try to keep sessions light humored and fun to promote engagement in this challenging work and make the exposure tasks more tolerable. Therapists can utilize the creativity of younger children to help this process. For one of Danny’s exposure tasks around resisting evening up, Danny devised an “exposure obstacle course” where he and his father competed against each other to complete differing tasks. For example, one station involved wiggling his right arm and right leg for 10 seconds without moving his left side, and another station involved kicking a ball with only his right foot. This helped the task to be fun and active, while still ensuring a focus on exposure. However, something therapists need to be aware of when doing this is there is a risk this may provide a distraction from the exposure task. This may undermine the process of distress tolerance or bring anxiety down, which means the child will not learn that anxiety habituates naturally. It is important that the child focuses on the feared stimuli for as long as possible (Benito & Walther, 2015). Parents can be given the task to describe the feared stimuli, along with the child, and to take distress ratings, to keep their focus on the exposure. For example, while Danny and his father competed on the obstacle course, Danny’s mother asked him for his anxiety ratings, and interjected with “Does your left side feel funny?,” “Does Grumpalump want you to even up?” “Well done you are doing brilliantly to annoy Grumpalump.” These comments ensured that Danny remained focused on the anxiety. Younger children generally may struggle to stay focused on tasks and may discuss other topics, which provides a distraction. It is helpful to introduce time after the exposure task where they can talk

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about their favorite topics. This can be used as a reward for completing the task, but also does not deny them the opportunity to talk about other things! If sessions can be fun and rewarding without undermining the exposure process, this can facilitate the process of inhibitory learning (Craske et al., 2014) whereby the child gets a different experience of the feared stimuli. Children should be praised for the attempts they make to engage in exposure tasks, rather than the outcome of the task. For example, if therapists hold in mind the anxiety habituation model and say the task ends once the anxiety habituates, young children may give inaccurate ratings as a way to end the task as soon as possible. The therapist and parent should give praise for the child approaching their feared stimuli; praise needs to be specific and immediate. Young children should be congratulated on tolerating anxiety and their bravery, rather than the outcome of the task. It is also important to remember, parents require praise too when supporting their child implementing tasks. It is important to highlight to them that they are doing well supporting their child with the task. If the child is struggling to engage in the tasks, it may be a sign that the task set may be too difficult for them. The therapist may then have to break tasks down into smaller steps and move slowly up the steps with young children. For example, as you may recall, Parveen’s original hierarchy, which included approaching different types of dogs, had to be broken down into how close she would get to these dogs. They may also struggle to accurately identify their emotions and rate anxiety when doing a task. Therapists may find the child has underestimated their distress, so they may find tasks harder than expected. Therefore therapists should be prepared to adapt tasks with new information they attain in session and be ready to break tasks down. When engaging in exposure, it is important that the child is able to communicate their distress ratings regularly during the task using their anxiety rating scale. It is likely they may struggle with subtle changes in anxiety so you may consider taking ratings every 10 15 minutes rather than every 5 minutes, to allow them to recognize changes. The goal of the session is not that their anxiety should have completely habituated by the end, but rather they approached something they were scared of and could tolerate the anxiety. If the child is struggling to rate their anxiety, parents can give their ratings as they are likely to recognize signs of distress in their child. Additionally, therapists can make behavioral observations when setting up tasks to establish how difficult they may be based on how readily the child approaches their feared stimuli and their reports of being able to resist compulsions or safety behaviors. After completing an exposure task, it is important to review the hierarchy in each session to adjust steps with the new information gathered to set realistic goals for tasks. With Parveen, the pictures of the dogs were

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moveable on her volcano model; after each session, the pictures were moved to indicate how scary she found the task now it was complete and to see if other pictures needed to be repositioned with this in mind. This also gave her a chance to take the tokens she had earnt from the volcano. In addition, photographs were taken of her completing each task and these were stuck onto the volcano as a reminder of her bravery and success, which encouraged her to move up the hierarchy. It is important to monitor the pace at which the child is working through their hierarchy during treatment. One of the challenges is to agree a pace between the child, parents, and therapist. There will be a time frame for therapy and goals for treatment, so it is helpful to review these regularly. It is important to aim for the child and family to feel challenged and that they are making progress in each session. The ultimate goal is for the child and parents to build up their confidence in setting up and implementing exposure tasks so they are able to implement this outside of treatment; whether this is between sessions for homework or after treatment ends. As exposure sessions progress, it is helpful to ask parents to lead in designing and implementing the exposure of the tasks, in a graded fashion, to help build up their confidence to take a lead on this. For example, here is a session with Danny and his parents when they were setting up and doing a task:

Therapist

Right Danny, we are going to set up a challenge today! Let’s look at the Grumpalump challenge sheet—wow—look how much you have done so far! What is going to be the challenge for today?

Danny

I don’t know

Therapist

Shall we ask Mum and Dad to pick a challenge each and then you can decide between the two options?

Danny

I don’t know

Therapist

Hey, do you know what? I forgot to ask, what did you decide would be the prize for getting ten tokens this week?

Danny

Mummy and Daddy said I could get a soccer magazine

Therapist

Fantastic. So how many tokens do you have to get up to 10 tokens today?

Danny

I just need two more!

Therapist

Yay! Right, Mum, Dad—let’s have a look at Grumpalump list—where have we got to? Right, can you pick a task that is the next step which will earn Danny his final two tokens!

Dad

I think Danny should hop on one leg only for 2 minutes

Mum

I set Danny challenge of tapping the soccer ball only once (Continued)

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(Continued) Therapist

Great job! Danny, which one do you think you will be able to do to get your tokens so you can get your prize?

Danny

I will hop.

Therapist

Amazing! Now before we get started—let’s do a reminder of what the challenge is for Mum and Dad during the task

Danny

Dad—you hop with me and shout back at Grumpalump and Mummy you have to ask me what color I am on my chart before and after I hop

Therapist

Great team work! Does everyone know what they are doing? Great, ready, set, go!

Challenging issues Behavioral difficulties Younger children who have anxiety difficulties may also present with challenging behavior such as temper tantrums, aggressive behavior, and destruction of property. This is often a way they demonstrate their anxiety, therefore is secondary to the anxiety disorder. However, this behavior can interfere in the process of exposure therapy as the focus of sessions may shift to managing the behavior as opposed to the exposure tasks. If these behavioral outbursts are formulated as an indication of anxiety, it is important to continue with exposure therapy as planned, as evidence suggests they reduce as the anxiety disorder, such as OCD, gets better (Krebs et al., 2013). In order to facilitate the process of exposure therapy in such instances, as discussed earlier, it is important to continue to externalize the anxiety disorder and encourage parents to blame the anxiety disorder and not the child. Parents may find it helpful if therapists normalize temper outbursts, by framing them as the “fight” part of the anxiety “fight or flight” response. It is important to reassure parents that temper outbursts will subside as the anxiety disorder gets better and therefore joint efforts should be focused on challenging the anxiety problem. This is especially relevant for family accommodation as reducing this improves challenging behavior in the long term, following a short-term increase in such behavior (Lebowitz, Omer, & Leckman, 2011; Storch et al., 2015). It is, however, helpful to ensure that parents understand that although the anxiety disorder might be the reason for outbursts, it is not an excuse for unacceptable behavior and this should not prevent sensible parenting (e.g., putting boundaries in place for unacceptable behavior such as hitting). Parents should also be encouraged to praise their child when they manage their anxiety without an outburst.

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If the behavioral difficulties are not formulated as part of the anxiety disorder, it is important to consider if they are indicative of disruptive behavior disorder as it has been found in OCD that this can lead to poorer outcomes (Storch et al., 2008). In such cases, it may be helpful to consider if parents need specific parent management treatment, which has been found to augment CBT for young people with comorbid oppositional defiant disorder (Sukhodolsky, Gorman, Scahill, Findley, & McGuire, 2013).

Child refusing treatment In some cases, children may completely refuse to engage in sessions, despite the use of contingency management techniques and play to engage them. If this is the case, all is not lost as many CBT protocols for younger children have been developed to work just with parents (Rapee et al., 2010; Rudy et al., 2017) and have been found to be equally effective as those including children in sessions (Waters, Ford, Wharton, & Cobham, 2009). The components of treatment remain the same as mentioned previously, but parents would be encouraged to apply techniques with their child at home (e.g., having a discussion of fears and developing a hierarchy, exposing the child step by step to the feared stimulus). If the child refuses to engage in the work at home, parents may wish to take charge and implement exposure without the child necessarily being aware this is happening (e.g., exposing the child step by step to their fear and rewarding them for doing so). If the child is unable to approach the feared stimulus, parents may decide to start with reducing their accommodation of the difficulty (e.g., if they have to give reassurance). In such cases, it is important that parents say to the child they are planning to challenge their fears with them and what to expect, so the child is not shocked when this happens.

Parental factors and family dynamics As family involvement is vital to exposure work with younger children, unhelpful parental, and family factors can have a negative impact on the therapy. Children whose parents experience psychopathology or caregiver stress are at a higher risk to benefit less from CBT (Compton et al., 2014; Southam-Gerow, Kendall, & Weersing, 2001). Indeed, such parental factors may have more of an effect for younger children (Berman, Weems, Silverman, & Kurtines, 2000). Children are found to be at an increased risk of developing symptoms of anxiety if their parents have an anxiety disorder (Hirshfeld-Becker & Biedermann, 2002), or if they have been raised with parental-anxious rearing strategies (Muris &

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Merckelbach, 1998). This increased risk may be attributable to a parent modeling fear or avoidance Muris, Steerneman, Merckelbach, & Meesters, 1996), overprotecting the child (Hirshfeld, Biederman, Brody, Faraone, & Rosenbaum, 1997), attempting to control the child’s behavior in a way that limits psychological autonomy (Hudson & Rapee, 2001), or facilitating avoidant coping responses (Dadds, Barrett, Rapee, & Ryan, 1996). In addition, family accommodation, whereby family members alter their behavior to mitigate the anxiety their child experiences, is found to be commonplace in childhood anxiety disorders (e.g., Lebowitz et al., 2013). These behaviors often represent well-meaning attempts of parents to help their child cope with anxiety. However, therapists are therefore likely to work with parents who both experience anxiety, and have developed unhelpful beliefs or strategies around managing anxiety. The optimal approach for managing unhelpful family dynamics is likely to depend on the extent of associated impairment. Clinical experience suggests that lower level parental criticism and over-involvement can often be successfully addressed in the context of family-based CBT without deviating from standard, evidence-based protocols. For example, Danny’s parents blamed him and were critical of compulsive behaviors because they did not have a good understanding of OCD. In his case, the therapist highlighting that compulsions are anxiety-driven, externalizing OCD and framing it as a bully that Danny was struggling to stand up to, rather than him being naughty, helped his parents to develop empathy and reduce criticism. For Zara who was overprotective of Parveen, she learnt the importance of confronting fears and anxiety habituation in therapy, which helped her to move forward. However, if parental distress significantly interferes despite attempts to address it within therapy, or the therapist suspects a parent may have their own psychological difficulties that may warrant support, it is important to share this with the parent and support them in accessing their own help. In cases with higher levels of family dysfunction, therapists may wish to consider additional techniques or family therapy as an adjunct to exposure therapy to increase chances of treatment success. For example, positive family interaction therapy, which was designed as an adjunct to CBT for OCD in highly distressed and impaired families with difficult dynamics, improved treatment outcomes compared with CBT alone (Peris & Piacentini, 2013; Peris, Rozenman, Sugar, McCracken, & Piacentini, 2017).

Conclusion This chapter presents suggested modifications to ensure that exposure therapy is accessible, engaging and effective for young children. It is important to adapt material according to the child’s developmental

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level, include the family throughout treatment, incorporate play-based methods, and use contingency management techniques. It is hoped that this chapter provides therapists with inspiration for how to facilitate exposure therapy with young children and the potential adaptations necessary to enable good outcomes.

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Freeman, J., Garcia, A., Frank, H., Benito, K., Conelea, C., Walther, M., et al. (2014). Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 43(1), 7 26. Grave, J., & Blissett, J. (2004). Is cognitive behavior therapy developmentally appropriate for young children? A critical review of the evidence. Clinical Psychology Review, 24(4), 399 420. Harter, S. (1990). Processes underlying adolescent self-concept formation. In R. Montemayor, G. R. Adams, & T. P. Gullotta (Eds.), Advances in adolescent development: An annual book series, Vol. 2. From childhood to adolescence: A transitional period? (pp. 205 239). Thousand Oaks, CA: Sage Publications, Inc. Herren, J., & Berryhill, J. (2018). Working with young children with OCD. In E. A. Storch, J. F. McGuire, & D. McKay (Eds.), The clinician’s guide to cognitive-behavioral therapy for childhood obsessive-compulsive disorder (p. 289). Academic Press. Higa-McMillan, C., Francis, S. E., Rith-Najarian, L., & Chorpita, B. F. (2016). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 45(2), 91 113. Hirshfeld, D., Biederman, J., Brody, L., Faraone, S., & Rosenbaum, J. F. (1997). Associations between expressed emotion and child behavioral inhibition and psychopathology: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 205 213. Hirshfeld-Becker, D. R., & Biedermann, J. (2002). Rationale and principles for early intervention with young children at risk for anxiety disorders. Clinical Child and Family Psychology Review, 5(3), 161 172. Hudson, J. L., & Rapee, R. M. (2001). Parent child interactions and anxiety disorders: An observational study. Behavior Research and Therapy, 39(12), 1411 1427. Izard, C. E. (1994). Innate and universal facial expressions: Evidence from developmental and cross-cultural research. Psychological Bulletin, 115, 288 299. Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66(1), 19. Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12(1), 136 148. Krebs, G., Bolhuis, K., Heyman, I., Mataix-Cols, D., Turner, C., & Stringaris, A. (2013). Temper outbursts in paediatric obsessive-compulsive disorder and their association with depressed mood and treatment outcome. Journal of Child Psychology and Psychiatry, 54(3), 313 322. Langley, A. K., Bergman, R. L., & Piacentini, J. C. (2002). Assessment of childhood anxiety. International Review of Psychiatry, 14(2), 102 113. Lebowitz, E. R., Omer, H., & Leckman, J. F. (2011). Coercive and disruptive behaviors in pediatric obsessive compulsive disorder. Depression and Anxiety, 28(10), 899 905. Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., et al. (2013). Family accommodation in pediatric anxiety disorders. Depression Anxiety, 30(1), 47 54. March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. Guilford Press. McGuire, J. F., & Storch, E. A. (2019). An inhibitory learning approach to cognitivebehavioral therapy for children and adolescents. Cognitive and Behavioral Practice, 26(1), 214 224. Mischel, W., & Metzner, R. (1962). Preference for delayed reward as a function of age, intelligence, and length of delay interval. The Journal of Abnormal and Social Psychology, 64(6), 425.

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Muris, P., & Merckelbach, H. (1998). Perceived parental rearing behavior and anxiety disorders symptoms in normal children. Personality and Individual Differences, 25(6), 1199 1206. Muris, P., Steerneman, P., Merckelbach, H., & Meesters, C. (1996). The role of parental fearfulness and modeling in children’s fear. Behavior Research and Therapy, 34(3), 265 268. Ollendick, T. H., Grills, A. E., & King, N. J. (2001). Applying developmental theory to the assessment and treatment of childhood disorders: Does it make a difference? Clinical Psychology & Psychotherapy, 8(5), 304 314. Peris, T. S., & Piacentini, J. (2013). Optimizing treatment for complex cases of childhood obsessive compulsive disorder: A preliminary trial. Journal of Clinical Child & Adolescent Psychology, 42(1), 1 8. Peris, T. S., Rozenman, M. S., Sugar, C. A., McCracken, J. T., & Piacentini, J. (2017). Targeted family intervention for complex cases of pediatric obsessive-compulsive disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56(12), 1034 1042. Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. American Journal of Psychiatry, 167 (12), 1518 1525. Rudy, B. M., Zavrou, S., Johnco, C., Storch, E. A., & Lewin, A. B. (2017). Parent-led exposure therapy: A pilot study of a brief behavioral treatment for anxiety in young children. Journal of Child and Family Studies, 26(9), 2475 2484. Russell, R. L., & van den Broek, P. (1988). A cognitive-developmental account of storytelling in child psychotherapy. Cognitive development and child psychotherapy (pp. 19 52). Springer. Southam-Gerow, M. A., Kendall, P. C., & Weersing, V. R. (2001). Examining outcome variability: Correlates of treatment response in a child and adolescent anxiety clinic. Journal of Clinical Child Psychology, 30(3), 422 436. Stewart, S., Geller, D., Jenike, M., Pauls, D., Shaw, D., Mullin, B., et al. (2004). Long-term outcome of pediatric obsessive compulsive disorder: A meta-analysis and qualitative review of the literature. Acta Psychiatrica Scandinavica, 110(1), 4 13. Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R., Lehmkuhl, H. D., Jacob, M. L., et al. (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), 583 592. Storch, E. A., Salloum, A., Johnco, C., Dane, B. F., Crawford, E. A., King, M. A., & Lewin, A. B. (2015). Phenomenology and clinical correlates of family accommodation in pediatric anxiety disorders. Journal of Anxiety Disorders, 35, 75 81. Sukhodolsky, D. G., Gorman, B. S., Scahill, L., Findley, D., & McGuire, J. (2013). Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: A multiplebaseline across-responses design study. Journal of Anxiety Disorders, 27(3), 298 305. Waters, A. M., Ford, L. A., Wharton, T. A., & Cobham, V. E. (2009). Cognitive-behavioral therapy for young children with anxiety disorders: Comparison of a child 1 parent condition versus a parent only condition. Behavior Research and Therapy, 47(8), 654 662. Weisz, J. R., Weisz, B., Han, S. S., Granger, D. A., & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117(3), 450. Woods, P. (2009). Alternative education for the 21st century: Philosophies, approaches, visions. Springer. Zavrou, S., Rudy, B., Johnco, C., Storch, E. A., & Lewin, A. B. (2019). Preliminary study of family accommodation in 4 7 year-olds with anxiety: Frequency, clinical correlates, and treatment response. Journal of Mental Health, 28(4), 365 371.

III. Developmental considerations

C H A P T E R

13 Using exposure with adolescents and youth adults Shannon M. Bennett1 and Anne Marie Albano2 1

Weill Cornell Medicine and New York Presbyterian Hospital Youth Anxiety Center, New York, NY, United States, 2Columbia University Medical Center and New York Presbyterian Hospital Youth Anxiety Center, New York, NY, United States

Using exposure with adolescents and young adults Adolescence and young adulthood are pivotal developmental stages and periods of significant risk for the emergence of psychiatric illness, particularly emotional disorders including anxiety disorders and mood disorders. Clinical trials and meta-analyses demonstrate cognitive behavioral therapy to be efficacious for adolescents and young adults with moderate to large effect sizes (Barlow et al., 2017; Bentley et al., 2017; da Silva et al., 2017; Kendall & Peterman, 2015; Walkup et al., 2008). However, important biological, ecological, and cultural considerations for these key phases of life must be considered in order to maximize the efficacy and impact of exposure therapy. This chapter describes the developmental stages of adolescence and young adulthood, and the related implications and recommendations for completing successful exposure-based therapies with youth in this phase of life. The chapter begins with a brief description of the major developmental goals of each stage, and then offers developmentally specific considerations for exposure therapy, including the appropriate inclusion of parents and families, developmentally informed assessment tools, and a stepby-step exposure-based treatment guide with clinical examples. The chapter concludes with additional special considerations and future directions for exposure work with this age group.

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Developmental stage of adolescence Adolescence is a developmental phase marked by physical and psychological change. The onset of puberty marks the beginning of significant changes in the biological, cognitive, emotional, and social functioning of youth as they move through this stage toward greater behavioral autonomy and self-control. Cognitive, social, and emotional milestones in adolescence include the development of metacognition (thinking about one’s own thinking, strategizing in learning); abstract cognitive skills (recognition of potential consequences, hypothetical reasoning, perspective-taking, future-oriented thinking); increasing importance and intimacy of peer relationships; and transformations in the parent/child relationship marked by a push/pull between dependence and independence (MacLeod & Brownlie, 2014). Adolescence is also a stage of life marked by an escalation in risk-taking behaviors. An increase in appetitive social and risk-taking behaviors may be explained, at least in part, by a proposed imbalance in adolescent brain development characterized by heightened sensitivity to motivational cues and emotional reactivity, coupled with immature cognitive control (Casey, Jones, & Somerville, 2011). The hormonal, structural, and neurobiological changes in the brain during adolescence, coupled with the tumultuous social, cognitive, developmental, and cultural demands of this stage of life are reflected in the surge in prevalence of anxiety and mood syndromes during adolescence. Half of all lifetime cases of mental illness onset prior to age 14, and the median age of onset for anxiety disorders and impulse control disorders is age 11, underscoring the importance of effective treatment in adolescence (Kessler et al., 2005; Merikangas et al., 2010).

Implications for exposure therapy Exposure therapy is based on the principles of fear extinction, such that cues associated with threat are presented in a controlled way until they are experienced as safe and fear responses are reduced or tolerated with less functional impairment. Some evidence suggests the impact of exposure therapy specifically may be attenuated for adolescents when compared to children or adults (Drysdale et al., 2014; Peris et al., 2015), yet other animal and clinical studies further suggest strategies for remediating this difference, such as the timing, prioritization, and context of exposure exercises (Pattwell, Bath, Casey, Ninan, & Lee, 2011; Peris et al., 2017). For example, studies in mice and non-anxious humans have demonstrated cue-based fear extinction learning to be less robust in adolescence than it is in childhood or adulthood (Pattwell et al.,

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2011). However, mouse models suggest that context-based extinction learning closes the gap between age groups, with adolescent mice performing as well on extinction learning tasks when put back in the original environment where the fear was acquired (Hartley & Lee, 2015; Pattwell et al., 2011, 2012). Similarly, clinical research suggests that exposure therapy is most useful when exposures are conducted in the same or similar environments to where the fear is experienced in everyday life (Conelea et al, 2014). Together, these findings suggest that exposure therapy will be most efficacious for adolescents if the exposure exercises occur in contextually salient and real-life environments and situations. Many skilled exposure therapists already practice exposures outside of the office to maximize generalizability from the intervention, however it appears to be even more crucial for adolescents and young adults to be exposed to in vivo approximations of the target stimulus in order for exposure therapy to be maximally effective. Further, exposure therapy is likely to be more efficacious for youth in general when it is prioritized early and often in the course of therapy, when more challenging exposures are completed, and/or when multiple exposure triggers are presented at once within a given session (Kircanski & Peris, 2015; Peris et al., 2017). In practice this means, the therapist should not avoid the “top of the hierarchy” exposures, encouraging adolescents to engage in the exposures that provoke the most distress, including those that may include multiple exposure targets at once (e.g., eating an odd number of items without washing your hands for someone who is concerned with even numbers and contamination).

Working with parents in adolescent exposure therapy Parents will be less explicitly involved in the exposure therapy of their adolescent child, as they may not be needed or wanted to facilitate the actual exposure as much as with a younger child, but parents are still crucial to the success of the exposure therapy process. Parents should be informed at each session about the progress the adolescent is making, what exposure they worked on in session, and what they should be working on during the week at home, school, or elsewhere. The therapist can work out with the parent and the teen in session how the parent can best support the youth in practicing the exposure during the week outside of the session. The adolescent will likely have strong feelings about how involved he or she wants the parent to be in terms of reminding the teen to complete the exposure, facilitating the exposure practice, and/or rewarding a successful practice attempt. In addition, the clinician, parents, and youth need to thoroughly understand

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the limits and bounds of confidentiality for issues discussed in the youth’s private sessions, as to what the adolescent or young adult wishes to remain confidential and what can be discussed with the parents. The therapist can help facilitate communication, planning, and compromise between the wants and needs of the adolescent and those of the parent. Parent training and education may also be integral to the success of exposure therapy. When parents of anxious youth engage in what is usually well-intentioned overprotection and over-accommodation of the anxiety symptoms, it prevents the teen from learning that they can cope on their own and learn from their mistakes. Indeed, this parental “rescue” often undermines the teen’s confidence that they can manage a normal amount of anxiety and stress on their own, and may diminish the efficacy of exposure therapy (Merlo, Lehmkuhl, Geffken, & Storch, 2009). Parental behavior can be discussed and changes recommended to support the gradual exposure of the teen to appropriate and predetermined doses of stress and anxiety via exposure, and parental accommodation strategies should be identified and lessened over time.

Maintaining motivation Adolescence is a time of strong social drive and motivation. Peers become a primary source of observational learning and social referencing, and begin to the eclipse the family of origin in terms of behavioral influence over the course of adolescence (Forehand & Wierson, 1993). The suggested implications of this are twofold: if youth are avoiding important social contexts and situations (school, parties, extracurricular activities) for mental health reasons (social anxiety, anhedonia, separation anxiety, overfocus on academics due to perfectionism, or to mitigate compulsive rituals) the potential functional consequences of missing out on opportunities for social learning are significant. Second, the power of social motivation can be harnessed to motivate adolescents and young adults to participate in anxiety-provoking or aversive exposure exercises. Conducting exposures in group therapy settings can be especially salient and useful for adolescents and young adults (see Albano, 1995). Teens will often appreciate the perspective of their peers in group therapy, even more than the therapist or other important adults, and teens may be more motivated to try a challenging exposure or practice a particular coping strategy if they are encouraged to do so by a peer. Social experiences can also be used as a natural reward for completing exposure tasks, such that overcoming one’s fear will allow the youth to participate in a social event they have previously avoided but will

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enjoy doing. This natural reward can be implicit or explicit, for example, “practicing exposure to eating foods at restaurants you fear may be ‘contaminated’ will allow you to join your friends in going out to lunch during lunch period” (implicit, naturalistic reward); or parents can set up an external reward plan, e.g. “when you have completed three exposures on your hierarchy this week, you can stay out one hour past curfew this weekend.”

Developmentally appropriate treatment models for adolescents Historically, the majority of evidence-based, exposure-oriented therapies lacked developmental specificity for adolescents, in that most were downward extensions of adult treatment programs or upward extensions of child-oriented treatments, with little consideration for the unique needs of adolescents (Holmbeck et al., 2000; Weisz & Hawley, 2002). The following research supported treatments offer developmentally informed, exposure-based therapy models for adolescents. The “Stand Up, Speak Out” program by Albano and DiBartolo (2007) offers an evidence-based model for the individual or group treatment of social anxiety disorder in adolescents. The Unified Protocol for Emotional Disorders in Adolescents is a flexible, transdiagnostic, exposure-based therapy for anxiety and mood disorder symptoms in youth (EhrenreichMay, Kennedy, Sherman, Bennett, & Barlow, 2018). A comprehensive guide for working with parents and families on emotion regulation and family problem solving in the context of exposure therapy can be found in Peris and Piacentini’s (2016), Helping Families Manage Childhood OCD.

Developmental phase of emerging adulthood The developmental stage of “Emerging Adulthood” describes the period of life roughly between age 18 and 29, with a specific focus on ages 18 25, when youth are no longer considered “teenagers” but are not yet fully “young adults” (Arnett, 2000, 2014). Thus, this phase of life is considered to be an “age of in between” (Arnett, 2000) and a “turning point” in one’s life (Schwartz, 2016) marked by a search for identity, a time of instability, a period of self-focus, and a sense of great possibilities. This relatively new developmental stage is marked by the fact that in the 21st century in developed countries it is the norm for young people to spend years trying different jobs, different romantic partners, and different living situations before “settling down” into more typical adult life. For example, Arnett (2014) collected survey data from young adults suggesting that during this phase of life 33% of respondents move to a

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new residence each year, 40% move back in with their parents at least once, young adults hold an average of seven jobs during their 20s, twothirds enter college after high school, two-thirds live with a romantic partner “for a time,” and that young people are getting married on average at least five years later than the prior generation. These statistics reflect the tumultuous social and behavioral changes and stressors that are unique for young adults in that they are ubiquitous in this phase of life.

Developmental tasks of emerging adulthood Based upon Arnett’s work, Albano and colleagues articulated several important developmental milestones and behavioral tasks of young adulthood (see Table 13.1; from Guerry, Hambrick, & Albano, 2014). Like earlier developmental milestones of childhood and adolescence, these are achieved along a continuum of development and maturation, and can be inappropriately stalled by psychological, psychiatric, and familial factors. Broadly, the long list of emerging adult milestones can be captured by four categories articulated by Arnett (2000, 2014): behavioral independence, identity formation, accepting responsibility, and socialization. A history of youth behavioral avoidance and/or parental over-accommodation can deprive youth of the skills necessary to achieve independence and leave them dependent on parents or unsuccessful in mastering these milestones (see Hoffman, Guerry, & Albano, 2018). This translates into significant functional impairments when young adults are not sufficiently skilled to take care of oneself when they go to college for the first time, in finding and keeping a stable job, in maintaining meaningful relationships, and/or in taking care of one’s own needs (physical, emotional, self-care, etc.).

Implications for mental health and exposure treatment In a national survey of a nonclinical sample of emerging adults (Arnett & Schwab, 2012), 56% of respondents endorsed that they “often feel anxious” and 33% reported that they “often feel depressed.” Concurrently, multiple epidemiological surveys confirm that this stage of life is one of the highest periods of risk for the emergence of major mental illness. The lifetime prevalence of mental disorders is roughly 50% (Kessler et al., 2005), and for 75% of these cases, the age of onset is prior to age 24. The median age of onset for substance use disorders is 20 years, and the median age of onset for mood disorders is 30 years (Kessler et al., 2005). College counseling centers have become overwhelmed in recent years with the number of young people presenting

III. Developmental considerations

TABLE 13.1

Developmental tasks of emerging adulthood.

Young adult milestones Task

Behavioral indicators

Establish emotional independence from parents

Manages disappointment or challenges on own with seeking advice appropriately as needed and weighs options; takes responsibility for own feeling states and reactions

Develop self-identity

Affirmatively describes self in terms of aspirations, interests, abilities and skills; recognizes own limits

Establish behavioral independence from parents

Takes initiative and completes tasks on own; asserts self to meet needs

Manage money responsibly

Manages own money acceptance of meeting responsibility for making reasonable and within budget purchases for food, clothing, and other needs; Manages finances so that relaxation/ hobbies/interests are pursued without overextending

Make and keep longterm friendships

Seeks appropriate social relationships on own and engages in activity to keep relationships on good terms; problem solves and mends strained relationships when appropriate

Controls personal selfcare

Grooms self without prompting; regulates own sleep patterns; Aware of and engages in healthy diet and exercise routine; Selfsoothes appropriately

Controls personal medical/health care

Makes regular appointments in timely way (annual physical; mental health visits; dental care); Seeks health care consultations as needed and in timely way; manages medications on own

Engage and accept sexual identity

Is engaged in pursuing sexual knowledge and understands own sexual identity; accepts sexual identity

Form romantic relationships

Has interest in and pursues romantic partner(s) in a healthy and meaningful way

Formulate and engage in long-term vocational goals

Able to articulate interests and pursue education or training in areas related to the interest; develops set of skills/abilities to pursue goals

Complete educational requirements

Completes compulsory educational requirements of high school or equivalent; seeks further education to pursue goals for career/vocation

Establish financial independence

Earns and saves own money

Lives independently

Moves away from home; establishes own residence and maintains all aspects (financial, upkeep) on own

Versions of this table appear in: Guerry, J., Hambrick, J., & Albano, A.M. (2014). Adolescent social phobia in clinical services. In K. Ranta, A. M. La Greca, L-J Garcı´a-Lopez, & M. Marttunen (Eds.), Social anxiety and phobia in adolescents (pp. 201 223). Springer, USA, and Detweiler, M.F., Comer, J., Crum, K.I., & Albano, A.M. (2014). Social anxiety in children and adolescents: Biological, psychological, and social considerations. In S. G. Hofmann & P. M. DiBartolo (Eds.), Social Anxiety: Clinical, developmental and social perspectives (3rd ed., pp. 254 309). Amsterdam: Academic Press.

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with significant impairments from anxiety and mood disorders, including self-harm and suicidality, and these rates appear to be increasing from past reports. A 2016 survey from the American College Health Association indicated that 62% of students report “overwhelming anxiety,” which was an increase from 50% in 2011. The Higher Education Research Institute at the University of California Los Angeles (UCLA) reported that 41% of incoming college freshman described feeling “overwhelmed with all I had to do during the previous year,” which was an increase from 29% in 2010 and 18% in 1985. However, despite the increasing numbers of young people seeking support from college counseling centers or similar programs, a large number of young adults continue to go undiagnosed and untreated (up to 75% in some studies), despite the high rates and risks of mental illness (Blanco et al., 2008; Cadigan, Lee, & Larimer, 2018). The consequences of avoiding academic, social, occupational, selfcare or other important behavioral tasks at this stage of life can result in significant functional impairment that may go unrecognized because young adults are more responsible for their own independent behavioral functioning, and may seriously impede progress on important developmental goals. Thus, exposure therapy is paramount in this stage of life to keep the youth engaged in their daily activities and responsibilities as much as possible. Many young adults who have suffered from anxiety or mood disorders since childhood or adolescence will be ill-prepared for the transition to independent functioning that often comes around age 18 with the move to higher education or first employment. Youth with a history of internalizing or externalizing disorders may have missed developmental milestones, or will have fallen behind their peers in their ability to successfully navigate the tasks of adulthood on their own. Past avoidance or accommodation of anxiety, often facilitated by well-meaning adults (parents, teachers, tutors, school counselors, non-exposure-oriented therapists), has stalled the development of problem solving, emotion regulation, organization, planning, and social skills necessary for successful advancement through emerging adulthood milestones.

Changing role of parents Despite emerging adults often moving away from home for at least some part of this developmental phase, a national survey study of 1029 young adults and their parents (Arnett & Schwab, 2012) suggested that 52% of respondents were in daily contact with their parents (67% with moms, 51% with dads), and that this lessened with reported age but remains quite high throughout the decade following high school (65%

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for 18 21year olds, 58% for 22 25 year olds, 50% for 26 29 year olds). Interestingly, 34% of young adults reported their parents are “more involved than I want them to be” suggesting a push/pull between independence and dependence. The dependence may in part be fueled by financial concerns as 44% reported they received frequent or regular financial support from their parents, with 30% reporting occasional support and only 26% reporting little to no financial support.

Implications for parent work with young adults When youth turn 18, they age out of pediatric care and are often required to enter into adult care facilities. These programs or providers are typically trained to care for adults well into their 60s and beyond, and the developmental lens that is so key to this early stage of adult life may be lost or overlooked. In group treatment settings, a young adult may feel as though they have no peers or cohort who can identify with their experience, and instead may be grouped with chronically mentally ill adults, where even the most well-functioning adult is at a different phase of life in terms of career and family goals. Parents are often completely excluded or left out of the treatment process, despite all of the intricate family dynamics outlined above that play a role in the cycle of functional impairment and dependence on others.

Developmentally appropriate treatment models The Launching Emerging Adulthood Program (LEAP; see Hoffman et al., 2018 for a full description) couples traditional exposure exercises with developmental milestone tasks to target both the symptoms and impairment associated with anxiety and avoidance, and to move young adults along toward a successful independent lifestyle. Typical daily self-care, social, educational, occupational, recreational, civic, or cultural tasks are assessed and discussed in this treatment through individual therapy, group therapy, and dyad parent/child session context, to identify areas of dependence and set weekly goals of independent completion of identified tasks. This treatment model strategically involves parents in key “transition sessions” to facilitate communication between parents and their young adult child to problem solve long-held patterns of joint anxiety, avoidance, and accommodation that have maintained the overdependence on caregivers and deficits in independent functioning. In these sessions, parents with transition tasks that they have taken over, back to their adolescent or young adult child, to facilitate the youth’s progress through development.

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With the above developmental, familial, cultural, and clinical considerations in mind, we now turn to a step-by-step approach for the successful implementation and utilization of exposure-based therapies for adolescents and young adults.

Assessment All strong treatment programs are based on reliable and comprehensive assessment. The following tools have been specifically developed or validated for adolescents and/or young adults, and their families, and will illuminate the requisite behavioral, developmental, familial, and symptom-driven considerations upon which to build an exposurebased treatment plan.

Clinician-administered interview The Anxiety Disorder Interview Schedule (ADIS) for Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5) is a semistructured diagnostic interview with distinct versions for use with adults and for children, adolescents, and their parents (Albano & Silverman, in press). The ADIS will assess the primary and co-occurring anxiety and related disorders, and data gathered via the interview will assist the clinician in assigning an associated clinical severity rating for each diagnosis. The semi-structured interview includes key behavioral checklists to assess areas of avoidance and impairment as a result of anxiety, panic, or depression, which will directly inform targets for exposure on a Fear and Avoidance Hierarchy (FAH).

Measures of behavioral functioning The FAH is a clinical tool that guides exposure therapy and is individual to each client. It should be developed collaboratively with the client and therapist, with input from parents or other important sources. It is an evolving document that should be revisited regularly to mark changes in anxiety and avoidance, progress in attempting specific exposure exercises, the addition of new or different exposure targets, and as a record of what the client has accomplished. An example of a FAH is provided in Fig. 13.1. Exposure targets are rated in terms of how anxiety provoking the stimulus or situation is (0 5 not at all anxiety provoking to 100 5 extremely anxiety provoking) and/or how much it is currently being avoided (0 5 not at all to 100 5 always and completely avoided).

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Assessment

Situation

Anxiety (0–100)

Avoidance (0–100)

Attempted Y/N or Date

1.

Going to a party if I don’t know anyone

95

100

N

2.

Asking someone out on a date

100

90

Y

4/12

3.

Walking into class late

85

85

Y

3/15

4.

Going to office hours for extra help

75

80

N

5.

Talking to my professor about my work

70

75

Y

3/1

6.

Asking questions in class

60

70

Y

3/1

7.

Having others read my work

65

70

N

8.

Talking with a classmate before class

55

55

Y

2/25

9.

Going out with my roommate and his friends

50

55

Y

2/15

10. Solve a problem without asking my parents

45

45

Y

4/1

11. Have a serious conversation with my parents

40

50

N

12. Go to a community organizing meet up

35

50

Y

2/12

13. Going to the gym

30

45

Y

2/14

14. Looking up summer courses

25

30

Y

1/30

15. Waking up on my own without my parents

25

30

Y

1/15

FIGURE 13.1 Example of fear and avoidance hierarchy. Please list situations that are currently anxiety provoking, and/or are avoided due to the experience of anxiety. For each situation, rate the degree of anxiety experienced in this situation, and the degree to which you wish to or try to avoid this situation. You can also note the date on which you attempt this situation for an exposure exercise.

The LEAP model also uses a Developmental Hierarchy to catalog progress with the developmental tasks of adulthood along a continuum of how independently the young adult completes each task (0 5 completely dependent to 100 5 completely independent) and how emotionally challenging each task is for the young adult (0 5 not at all challenging to 100 5 extremely challenging). These tools can be used simultaneously in treatment with specific exposure goals and developmental goals assigned each week in individual or group treatment modalities. The Launching Emerging Adults Form (LEAF; Albano et al., unpublished; Fox et al., 2018) is an inventory of developmental tasks and milestones of emerging adulthood for which the client, parents, and therapist can assess the degree of independence and/or dependence for the young adult, form the Developmental Hierarchy, and track progress over time. Domains of young adult functioning covered by the LEAF

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include self-care, finances, relationships and sex, work and school, daily living tasks, recreation, altruism, religious and political views, and emotional independence. The form can also be used with older adolescents and their parents as a compass for tracking what skills and milestones should be mastered in adolescence to best prepare one for the next stage of emerging adulthood. Adolescents should not be expected to be as far along on the dependent/independent continuum as an emerging adult. Psychometric evaluation of the LEAF is in progress.

Parent and family functioning measures A few specific self-report measures can also be helpful in identifying important parent and family variables that will influence the successful implementation of exposure programs with parent involvement. For example, the Family Environment Scale (FES; Moos & Moos, 1994) is a 90-item measure of multiple domains of family functioning, which includes 10 subscales that map onto three dimensions of family environment. The Family Accommodation Scale (FAS; Calvocoressi et al., 1999) is a 13-item self-report measure which assesses the degree of family accommodation of symptoms, including behavioral involvement and the family’s distress about the degree of involvement. The Family Accommodation Scale Anxiety (FASA; Lebowitz et al., 2013) is a similar measure specific to youth anxiety disorders. The Parental Attitudes and Behaviors Scale (PABS; Peris, Benazon, Langley, Roblek, & Piacentini, 2008) is a 24-item parent report measure assessing the degree of parent blame, accommodation, and empowerment around their child’s symptoms. The FAS and the PABS may be particularly useful to ascertain intervention targets for the parent sessions. Interestingly, scores on the Cohesion and Conflict subscales of the FES and the Blame subscale of the PABS predicted the efficacy of exposure therapy for youth with obsessive-compulsive disorder (OCD; Peris et al., 2012), and thus became important targets of parent and family work in the Parent Family Interaction Treatment model (PFIT; Peris, Rozenman, Sugar, McCracken, & Piacentini, 2017). In addition, there are important considerations for assessing the readiness and appropriateness of whether and when to include parents in the treatment process with an adolescent or young adult. First, the level of functioning of the youth is important to assess and address to determine the appropriate level of parental involvement. If the teen or young adult is severely depressed, suicidal, and/or engaging in self-harm behaviors, the parents must be engaged at the level of safety planning and appropriate monitoring. Deficits in emotion regulation that put the adolescent or young adult at risk for self-harm must be adequately

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addressed through other treatment modalities (e.g., medication, Dialectical Behavior Therapy), before engaging the youth in any exposure therapy paradigm. If the patient is relatively stable, safe, and functioning well enough to engage in an outpatient treatment program, then the next step is to assess the degree of conflict between the parents and the youth in order to determine how well they can work together in treatment. An assessment of how dependent the youth is on the parents relative to their age and developmental stage is key to fully understanding the impact of the symptoms, secondary gain from the symptoms that may interfere with motivation for exposure, and targets for exposure practices. Further, while the parents are not your presenting patient(s), having some understanding of the parents own psychiatric history and current psychopathology is crucial to determine whether the parents need to be in concurrent treatment in order to support their adolescent or young adult child’s success in treatment, and to understand the degree to which parents will be willing and able to participate in treatment. Parents with anxiety disorders may have a more challenging time pushing their youth to engage in exposure and independent functioning practices. Parents who are depressed may not have the energy to encourage their youth to follow through with treatmentrelated tasks. Parents with substance use, mania, or psychotic symptoms may be too unpredictable or unstable to rely on for support with the treatment process. If the parent is in their own treatment, it may be useful to obtain consent to speak with the parents’ treatment provider if possible to appropriately understand these variables. Other metrics of family functioning and family stress (e.g., financial stressors, marital relationship, family members’ health status) are also important to assess in order to determine the expectations for parental involvement.

Step-by-step treatment approach Psychoeducation Treatment should begin with relevant psychoeducation to aid in the understanding of the role of anxiety and related symptoms in perpetuating the avoidance that leads to insufficient skill development and under-achievement on developmental milestones. Education that describes and supports the process and rationale for exposure therapy is key to securing the youth’s buy-in prior to initiating any exposure practice. The rationale for exposure therapy should be reviewed at the onset of the treatment so the youth and family fully understand the

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therapy modality and are not surprised when exposure exercises are first introduced. For example, when providing psychoeduation about exposure-based therapies, the following topics should be included. Exposure is believed to be the most “active ingredient” in cognitive behavior therapy because it serves as the vehicle for integrating and practicing the cognitive and behavioral skills that have been previously learned or discussed in therapy. As discussed above, exposure exercises should be as “real life” as possible to trigger anxiety symptoms and approximate what the client experiences when confronted with fear and anxiety-provoking situations, and the accompanying urge to avoid in his or her daily life. The client should be reminded that they are a partner in selecting the exposure situation and intensity, and that the therapist will appropriately push and encourage them to try increasingly challenging exposures as they are ready, but will never force them to do anything they do not want to do. Exposures provide the opportunity to ideally attenuate the intensity of anxiety over time with repeated practice, and/or learn that anxiety can be tolerated without avoidance or safety behaviors, while increasing confidence and mastery in the use of adaptive coping skills and proactive problem solving. Repeated exposure exercises typically result in habituation to or increased tolerance of the experience of anxiety. Exposures may never completely eradicate anxiety, nor should they, as the experience of an appropriate level of anxiety is important and can be useful if handled appropriately. The cycle of negative reinforcement of avoidance and escape behavior is weakened and ideally extinguished over time. Furthermore, the practice of exposures is a powerful cognitive tool for gathering evidence to refute maladaptive and automatic anxious thoughts, and to practice confronting feared situations and stimuli while using and refining cognitive coping skills (e.g., cognitive restructuring, mindfulness, thought diffusion).

Skill building Emotion regulation skills that will aid in the competent and confident management of anxiety and fear are often useful to review and practice prior to initiating exposure therapy exercises. It is important to maintain a careful balance when discussing skill building to not engender an overreliance on coping skills to eradicate anxiety, or to send a message that it is not okay to experience the emotions of fear and anxiety. In fact, the goal of exposure therapy is to learn that one can experience and tolerate feeling these emotions and still pursue important and appropriate daily activities. Nevertheless, instruction and practice of appropriate coping

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skills including emotion regulation, cognitive restructuring, mindfulness, problem-solving skills, social skills, assertiveness skills, and/or behavioral control are all useful and included in the treatment programs above recommended (LEAP, Unified Protocol, etc.). The acquisition of appropriate and adaptive cognitive, social and behavioral skills will provide the young adult with key behavioral targets to practice when experiencing anxiety or fear, and over time will ideally replace the previous use of avoidance or other maladaptive coping skills. Parents can also feel more calm and confident knowing the youth now has adequate and adaptive coping strategies to handle emotions that may occur in the context of new or challenging situations. When pointed out by the clinician, this may allow parents to feel more comfortable taking a step back and refraining from any urge to “rescue,” protect, or over accommodate the adolescent or young adult. We will not focus on instructions for teaching or practicing the specific coping skills, as the focus of this chapter is exposure, however these skills are comprehensively outlined in the established treatment programs we have recommended. Moreover, which skills the therapist selects to work on should be personalized to the needs and goals of the patient and the treatment plan.

Exposure The rationale for exposure therapy bears repeating prior to the initiation of the first exposure exercise and as often as needed to maintain engagement and motivation as the exposure tasks become more challenging. The therapist will have worked collaboratively with the youth to establish the FAH early on in treatment and this document will serve as a roadmap for treatment planning, a communication tool to assess assumed and actual distress level during a given exposure, and to track progress over time. The therapist will work together with the youth, and sometimes the parents, to define, develop, and refine exposure situations both within session, and for home practice. The therapist and youth will process and evaluate each exposure exercise after it is completed to discuss how it went, what happened, how the youth felt and whether this changed over time, whether the youth’s or parents’ fears were substantiated, what was learned from the exercise, and how to build on the experience or take next steps. A discussion of natural or extrinsic rewards for engaging in the exposure can also be included, and if discussed a priori, then the therapist should ensure that the youth receives and/or experiences the predetermined reward, whether it comes from the parent or the youth. See Table 13.2 for common targets for exposure therapy for adolescents and young adults.

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Common exposure targets for adolescents and young adults.

Anxiety-provoking situation

Example exposure ideas

Class participation

Raising hand or reading aloud, answering if unsure of the correct answer, asserting an opinion about a topic; going to a community lecture on something you know nothing about

Interviews (job, high school, college)

Mock interviews, setting up real job interviews

Dating

(dating apps, talking to someone you’re attracted to, asking someone out)

School dances Parties or other unstructured social situations

Going to parties, street fairs, concerts, health clubs/gyms,

Being assertive

Ordering something and sending it back; asking someone to do something or to stop doing something

Talking to authority figures (teacher/professor, boss, principal)

Talking with store clerks, making returns

Being observed by others

All exposure tasks in group are observed by other group members

Taking tests

Class tests, SATs, GREs,

Meeting new people

Going to bookstores, cafes, restaurants; strike up a conversation with a safe stranger

Being wrong

Asking for ludicrous directions, or asking for directions in front of the destination

Initiating/maintaining conversations

Talking at lunch in cafeteria or dining hall, talking with others on the way to class, before the start of class, or in between classes

Performance situations

Putting in a job application, signing up for an improve class or toast masters, taking a dance class or learning a new instrument

Being alone

Going to a cafe´ alone, spending a night in by yourself

Turning off phone/social media

Determine increasing amounts of time to avoid using text, social media, Facetime, etc.

Feeling bored

Scheduling unplanned or unstructured down time

Being the center of attention

Commenting on social media posts

Not being able to escape

Taking public transportation

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Introduction to exposure There are a few exercises that can be useful to illustrate the psychoeducation concepts that are key to exposure readiness. The therapist can first approximate the arc of habituation with the youth using something that is neutral or less anxiety provoking. For example, the therapist and the youth can put sticky jelly on their hands or put a rock in their shoes, and see how the experience of these sensations of stickiness or discomfort change over time. Often, the sensation is diminished with time, and using distraction via a conversation about a topic of interest, or watching a brief video clip, can aid in the illustration of how we can gain control over the intensity of a sensation. To illustrate the power of negative reinforcement, the therapist can engage the youth in the mindful preparation for exposure. In the LEAP program, in the first session of the group-based exposure phase of treatment, members are told that they are going to give an impromptu talk in front of the group. This is a high-anxiety experience for many young adults, particularly those with social phobia. The therapist leads the members through a mindful examination of the thoughts, feelings, sensations, and urges they are experiencing as the speech/exposure moment approaches, and then tells the group that they will not engage in the exposure today and focusing each member’s attention on the relief that is experienced at hearing this. This is a salient way to explain the process of negative reinforcement that is associated with escape and avoidance behavior, the antithesis of exposure.

Use of confederates To maximize the ecological validity of an exposure exercise, other people can be included in the exposure session (called “confederates”), to offer additional practice opportunities outside of just with the therapist. Confederates can be other group members in a group therapy setting, other program faculty, or staff members that are less known to the patient, well-trained volunteers (students, assistants), or another person who has been trained and briefed by the therapist. Training should include extensive coverage of confidentiality since the confederate will be interacting with the patient during a particularly vulnerable time in therapy. Training should also include the general and specific goals of exposure for each patient, prior to engaging in the exposure. If there are particular practice targets for the patient (e.g., asking questions of another person via “small talk”) then, for example, the confederate would be explicitly told prior to the exposure to wait until the patient has asked them two or three questions before they ask the patient about themselves, or letting silences in the conversation “linger” before

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moving on to another topic. Some basic clinical training is important, such as monitoring the client’s level of distress to know when to push a little more in the exposure and when to pull back or end the exposure, making sure to not “rescue” the client too quickly if they have not yet met their goals. The client should always know ahead of time that confederates may be used in the exposure and they should be debriefed afterward, often with helpful feedback from the confederate, about what went well, and what to continue working on next time.

Review and relapse prevention When the goals of the exposure therapy have largely been met, the therapist will begin working with the youth to wrap-up treatment, plan for the future, and prevent future relapse of symptoms or return to impaired functioning. The end of treatment may be dictated by a predetermined requisite number or sessions, or may be flexible and determined by the client and therapist, depending on the nature of the program and funding for the treatment. Helpful benchmarks for knowing when to approach the end of exposure therapy include: when most of the targets on the FAH have been attempted, when the youth and parents know how to plan and execute exposures on their own, and/or when anxiety and interference ratings have decreased. Re-rating the FA hierarchy regularly will help the therapist, youth, and family track and visualize progress, as well as take stock regularly of what the youth has attempted, accomplished, and learned. As the end of therapy approaches, a review of psychoeduation, coping skills, and exposure principles is important, ideally led by the youth sharing what they have learned and what has changed as a result of their work in therapy. A list of future exposure goals and developmental or functional tasks that the youth will attempt, as well as the skills they will continue to practice, is an important document to create around the time of termination. This document should be made as specific and concrete as possible, including a schedule, time, and place for the youth to practice exposures and other skills to ensure follow-through. Gradually spacing out sessions to every other week or monthly, or offering booster sessions as needed, are ways to help the youth and family get comfortable with continuing the principles and goals of the exposure therapy on their own without the regular contact of the therapist.

Including parents in treatment sessions At all stages of exposure therapy with adolescents and young adults, it is important to keep parents involved to a certain degree, if possible.

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This will require formal consent if the youth is over 18. With all adolescents and young adults it is important to work out very early in the treatment what the parent involvement will look like, and how to make this feel the most useful and comfortable for everyone (youth, parent, and therapist). Discussing upfront what the goals of parent involvement are and why it is helpful to have parents connected to the therapy, as well as the principles and limits of confidentiality, are essential to successful parent integration. Parents and youth should both provide input as to what they feel are appropriate boundaries for confidentiality in the therapy, and the therapist can share the legal limits of confidentiality depending on the age of the youth. A discussion with the adolescent or young adult patient about parent involvement often involves talking about the specific areas of conflict that occur with their parents. Such conflict is often related to the youth’s avoidance of self-care activity (e.g., failure to shower, wake up on own, take medication on time), not pitching in around the house, and failure to pursue edifying activity such as volunteerism, work, or school. Using elements from motivation interviewing (MI), the therapist engages the youth in discussing the pros and cons of working with parents, with the idea of “getting them off your back” by taking responsibility in certain areas, and how this can also improve the mood in the home as well as their relationship. Further, use of MI assists in helping the youth to identify personally meaningful change that they are willing to make overall, as this will become part of their goals for treatment. Results of the youth and parent LEAF assessment further provides a way to highlight areas where the youth can grow in independence while having parents back out of taking over and inadvertently causing conflict. A plan for clear boundaries regarding confidentiality, and focus on specific tasks and issues that will be worked on in parent youth transition sessions, is agreed upon with the youth. With an older adolescent or young adult who is reluctant to include their parent(s) in treatment, an example of engaging the youth in discussing this part of treatment might include, “You are here to work on meeting goals that are important to you through managing your anxiety and mood and increasing your confidence that you can take steps towards these goals on your own. In order to support your growing independence, it would be helpful to have a session together with your parents to discuss all together how they can be helpful, without being too involved or taking over for you. You all want to have less arguing at home, so we can talk with them about how to work on that. You can each share the things you are worried about and we can make an agreement for what you are going to practice on your own, and what, if anything, they can do to support the work you are doing.”

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In strategically placed meetings with the parent and youth together, the goals for parent work will include: • Psychoeducation about avoidance and ideal parental response, improved communication, agreed upon goals for exposure and independence, youth and parent concerns and questions about the treatment process. • Psychoeducation for parents and youth on the role of overprotection and overcontrol in the maintenance of anxiety and avoidance symptoms is key to understanding how to change these interaction patterns. • Parents and youth should review together the developmental tasks of adolescence and young adulthood. The parent and youth can each complete their own version of the LEAF to determine how far along the developmental spectrum they each feel the youth is, and find points of agreement and disagreement to discuss. • Areas of frequent conflict are key to assess and discuss openly in joint sessions with parents. The role of youth or parent anxiety in these conflicts may be informative for all involved. • Parents and youth should each have a forum for expressing their fears openly and appropriately. This can include the parents’ fears about the youth’s mental health condition and trajectory, fears about the impairments in functioning they have accumulated and how to move past these, and fears about letting their child feel stress, flounder, or fail. • Similarly, the youth should express their own fears and frustrations about their condition, their interactions with their parents around anxiety-related situations and triggers, and their concerns about living life without the safety net of parents and the heavy anchor of anxiety. • Joint parent and youth sessions should enhance communication and incorporate effective communication strategies. Joint problem solving can be employed to negotiate areas of conflict or uncertainty. • Finally, parents and youth must come together to discuss and agree upon treatment goals and plans.

Clinical examples The following case examples of an adolescent and young adult treatment course will illustrate many of the principles of treatment outlined thus far in the chapter. Cindy (name and other identifiers have been changed) was a 13-yearold female with a diagnosis of OCD, Generalized Anxiety Disorder

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(GAD), and Social phobia. At the time of the initial assessment, Cindy reported that she was perfectionistic about schoolwork, worried a great deal about her grades and performance in school, worried about her friendships and family relationships, and worried about contracting an illness. She also reported experiencing frequent stomachaches and headaches, which contributed to her worries about illness. She engaged in compulsive behaviors to prevent herself from catching a disease or to prevent something else bad from happening. She reported engaging in time consuming rituals to bring good luck and prevent bad luck, like flicking light switches a certain number of times, avoiding touching things that are black, avoiding the number 13, avoiding saying certain words, walking a certain path down the street, wearing or not wearing certain clothes, and washing her hands frequently, and following a specific ritual in the shower. Cindy had a group of friends, but was overly worried about judgment from peers. She reported that she worried about saying the right thing, wearing the right thing, and her hair looking a certain way, which led to her changing her clothes multiple times, and spending too much time getting ready for school so she was often running late in the morning. She was very dependent on her parents for homework help and sought repeated reassurance from them if she was worried about contracting a disease. She would call her parents and ask to be picked up from school if she thought she had been exposed to germs or illness. She was very self-conscious about attending parties, dances, or bat mitzvahs, and often opted to stay home from these events at the last minute, even though she had felt excited about them previously.

Course of treatment Sessions 1 and 2 with Cindy focused on getting to know her, building rapport and discussing psychoeducation, including the threecomponent model of emotions, the role of compulsions and reassurance seeking as behaviors to temporarily cope with anxiety and distress, and the rationale for using exposure to help her develop an adaptive set of strategies for coping with her uncomfortable emotions. Sessions 3 5 focused on learning and practicing adaptive coping skills, while also practicing some lower level exposures from her hierarchy. She learned and applied cognitive restructuring to her worries and intrusive thoughts related to social concerns, school concerns, illness concerns, and safety concerns. She would then use cognitive restructuring in the context of an exposure task that elicited some anxiety to practice in session. Cindy and her clinician found that sometimes using cognitive restructuring repeatedly would became a form of reassurance seeking,

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so they instead opted to use mindfulness to observe the thoughts without changing or responding to the thoughts. She learned and practiced mindfulness skills as another way to observe her thoughts without getting stuck, and used this skill to tolerate the distressing thoughts that emerged during and especially after practicing exposures. She also learned and practiced deep breathing to help with some of her somatic symptoms and to help her fall asleep. Sessions 5 12 were focused solely on completing exposures from her FAH. These included practicing small talk with peers when in the hallway or in class, responding quickly so as to not overthink what she was going to say, resisting turning the lights on and off, touching things she thought were “germy” without washing, doing things odd number of times, reading about illness without performing compulsions, and touching or writing the number 13. She also practiced compound exposures, or tackling multiple exposure targets in one practice, such as eating lunch in the cafeteria which exposed her to food she considered to be “germy” or “gross,” while also having to manage the social concerns related to eating with peers. Cindy’s parents were included at the end of each session to learn what she had worked on that day, and to be a part of planning the exposures and skills Cindy would practice at home during the coming week. Additional time was spent with Cindy and her parents to discuss the ways in which her parents could gradually reduce their accommodation of Cindy’s compulsive rituals. The clinician also spoke with her school counselor to reduce the ways in which school was accommodating her rituals. For example, they set goals for Cindy to stay in her classroom and use her skills when she was anxious, instead of going to the nurse or the guidance counselor. The guidance counselor was informed of the skills Cindy was working on (e.g., mindfulness, exposure, cognitive restructuring) so she could remind her of these and then encourage her to use these coping skills and go back to class. Cindy and her parents worked together on structuring their morning routine to help Cindy do things more efficiently, like using timer in the bathroom to reduce washing rituals, parents not doing things for her to get her out the door, and not letting her take a car if she was running late and missed the bus. Cindy and her parents also worked on structuring their after school and evening routine to help Cindy get her homework done independently and efficiently, so that she could earn more time to relax and do something enjoyable with the family. They instituted rules about turning off electronics during homework and after a certain time in the evening to help Cindy stop checking social media compulsively, and go bed without electronics. Cindy’s parents also participated in three parent-only sessions to further address the ways in which they were accommodating her symptoms.

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In these sessions, they were coached to stop buying extra soap and body wash to reduce the amount Cindy was using, to utilize their own adaptive coping skills to manage the distress that led to them giving in to her due to their fear of her getting bad grades or their fear of making her upset. They started answering her questions just once instead of over and over again, stating I have answered this once and I’m not going to answer again. They were later able to stop answering the phone if she called multiple times about the same worry or stop responding if she texted the same question multiple times. Cindy was informed of these changes before the parents instituted them. Cindy and her parents were able to give each other points toward a family reward if they all completed an exposure successfully without parental accommodation, or if got the morning and afternoon routines completed smoothly. Cindy and her parents found that toward the end of treatment, things were more harmonious at home in the mornings and evenings. Cindy continued to experience some stress and anxiety about school, or if she heard about something bad on the news, but she was better able to manage the distress without compulsions and was able stay in class. She started to enjoy going to parties and bat mitzvahs, and made some new friends in her class who were not part of her immediate friend group and shared some different interests. After 12 sessions, the family came every other week for a few weeks and then ended treatment knowing they could return for booster sessions as needed in the future. Austin was a 21-year-old male with diagnoses of Social Phobia, Major Depressive Disorder, and GAD. He presented to treatment after leaving college during the second semester of his freshman year because he was failing several classes and was experiencing worsening depression and anxiety. Austin had moved to a new city for college and once away from his parents and other sources of support he struggled quite a bit to make friends, to get to class on time or at all, and to ask questions or meet with his professors if he was confused about an assignment. When he missed an assignment or was late too many times, he started avoiding certain classes altogether because he was afraid his teacher and classmates would judge him for arriving late or turning in late work. He was interested in some of the clubs and activities on campus, but at the last minute would usually opt to stay in his dorm watching TV or playing video games. He was friendly with his roommate who would invite him to go out or go to lunch, but Austin would usually make up excuses for why he couldn’t go saying he had too much work to do or had other plans because he was anxious about not having anything to talk about with his roommate’s friends whom he did not know well. As the semester went on, he isolated himself more and more which greatly impacted his mood. He started sleeping a lot more during the day and would try to stay up and get his work done at night, but since he was

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missing most of his classes he was often confused about how to complete the assignments and then was too embarrassed to turn them in or ask anyone for help. He enrolled in the LEAP in order to address his anxiety and depression while taking a semester off in hopes of returning to school the following year. Austin enrolled in individual treatment and joined a therapy group with other young adults also participating in the LEAP program. His individual therapy began with psychoeducation about the cycle of anxiety and avoidance, and included meetings with his parents to discuss the history of anxiety and avoidance that had led to his difficulties while at college. The family sessions illuminated a long cycle of dependency on his parents, with a focus on identifying the skills Austin had not yet mastered, because his parents were often stepping in when he needed extra help or support in school. He started practicing problemsolving skills, cognitive restructuring, assertiveness, and other social skills, both in individual therapy, as well as with his peers in group therapy. The group allowed him to meet peers who had similar struggles getting started with college and when living away from home, and to receive support and feedback from them during his process of therapy. He used cognitive restructuring to challenge his thoughts about being judged in social and classroom situations, particularly his belief that peers think he is weird and that professors will think he is stupid. Austin started engaging in exposure practices early on during individual and group therapy, as well as on his own between sessions, including going to “meet ups” for a political cause that he followed on social media, enrolling in a course at a local community college, making small talk with peers before and after the class, texting classmates to form study groups, talking to professors about his work, and initiating conversations with his parents about difficult topics like returning to college away from home. Austin also worked on completing life skills tasks from his developmental hierarchy, such as going to the gym three times per week, going to bed and getting up at on a regular and consistent schedule, learning to cook one to two meals per week instead of ordering all of his meals, learning to do laundry on his own, and visiting office hours for his class twice during the semester. Toward the end of his therapy, he took a three-week summer course away from home to challenge himself to change the patterns of avoidance that he got into when he was on his own at college. He was able to take on more independent tasks when he was away from home. Austin and his therapist noticed that he fell back into dependent patterns and conflicts with his parents when he returned after the three weeks away, so additional parent sessions were used to help Austin and his parents to communicate effectively about their feelings of fear and anger, and to problem solve how to best support Austin in his goal to return to college in the fall. III. Developmental considerations

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These examples illuminate the important concepts for successful exposure therapy with adolescents and young adults, including a strong foundation in the developmental tasks of these life stages, starting exposures early and supporting the youth toward the most challenging exposure exercises, strategically and effectively involving parents to facilitate and maintain treatment gains, and plan for treatment termination with relapse prevention. Additional challenges one may need to problem solve during the course of exposure therapy with an adolescent or young adult include the use or abuse of substances for managing distressing emotions, the use of safety behaviors to mitigate the effect of exposures, difficulty approximating contextual variables, and the appropriate use of electronics and/or social media. These are complex problems that could each command their own chapter. Serious substance use problems must be addressed and alternative adaptive coping strategies instilled prior to initiating exposure therapy. This may involve a rehab program, or regular drug and alcohol screening. However, occasional or recreational use of substances is quite common in youth, and if it is not dangerous or treatment interfering, then psychoeducation about the use of substances as a form of avoidance and setting goals in weekly treatment to reduce using, particularly in key anxiety-provoking situations (such as when socializing at a party) are important components to integrate into treatment. Other safety behaviors may include using medication, water, electronics, or other tools for distraction or self-soothing during exposure exercises. Look out for subtle avoidance patterns and set goals in treatment to eliminate these. For example, set an exposure goal to sit at a table alone in a cafe´ for a coffee or a meal without the youth’s smartphone anywhere in sight, or to say hello to three people on the way to class without wearing headphones and with good eye contact. Complete exposure practices outside of the office and in real-world contexts as much as possible. Virtual Reality is also a tool that is developing rapidly for contextually rich exposure practice opportunities. The use of social motivators and other rewards may help keep the youth engaged, especially during or after challenging exercises. Exposure therapy is not easy, but it is an effective and important tool for maximizing the functioning of youth during these critical stages of development. In sum, when working with an adolescent or young adult in exposure therapy it is imperative to consider the developmental context. This always begins with developing a therapeutic relationship and building rapport, setting goals that are important to the youth, and using these to enhance and maintain motivation throughout the exposure exercises and course of therapy. Contextually rich, real-world exposures that target areas of impaired functioning and move the young person toward meeting developmental milestones will maximize recovery from symptoms

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and long-term remission. The careful and collaborative involvement of parents to increase exposure support and scaffolding, decrease symptom accommodation, and promote healthy individuation will optimize outcomes from exposure therapy. Utilizing the importance of peers in this stage, either through group exposure therapy or as a natural or planned reward for engagement in exposures, is also a developmentally specific way to enhance exposure success and promote typical adolescent and young adult behavior. Encouraging independence with exposure practice over time and incorporating the principles of exposure into everyday life will help with relapse prevention and the eventual termination of therapy.

References Albano, A. M. (1995). Treatment of social anxiety in adolescents. Cognitive and Behavioral Practice, 2, 271 298. Albano, A. M., & DiBartolo, P. M. (2007). Cognitive behavioral therapy for social phobia in adolescents: Stand up, speak out, therapist guide. Oxford University Press, Programs That Work. Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through early twenties. American Psychologist, 55, 469 480. Arnett, J. J. (2014). Emerging adulthood: The winding road from the late teens through the twenties (2nd ed.). New York: Oxford University Press. Arnett, J. J., & Schwab, J. (2012). The Clark University poll of emerging adults: Thriving, struggling, and hopeful. Worcester, MA: Clark University. Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., SauerZavala, S., & Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. Journal of the American Medical Association Psychiatry, 74(9), 875 884. Bentley, K. H., Boettcher, H., Bullis, J. R., Carl, J. R., Conklin, L. R., Sauer-Zavala, S., & Barlow, D. H. (2017). Development of a single-session, transdiagnostic preventive intervention for young adults at risk for emotional disorders. Behavior Modification, 42(5), 781 805. Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S. M., & Olfson, M. (2008). Mental health of college students and their non college-attending peers: Results from the national epidemiologic study on alcohol and related conditions. Archives of General Psychiatry, 65(12), 1429 1437. Cadigan, J. M., Lee, C. M., & Larimer, M. E. (2018). Young adult mental health: A prospective examination of service utilization, perceived unmet service needs, attitudes, and barriers to service use. Prevention Science, 62(12), 1510 1513. Available from https:// doi.org/10.1007/s11121-018-0875-8. Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., & Price, L. H. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior. The Journal of Nervous and Mental Disease, 187(10), 636 642. Casey, B., Jones, R. M., & Somerville, L. H. (2011). Braking and accelerating of the adolescent brain. Journal of Research on Adolescence, 21, 21 33. Conelea, C. A., Walther, M. R., Freeman, J. B., Garcia, A. M., Sapyta, J., Khanna, M., & Franklin, M. (2014). Tic-related obsessive-compulsive disorder (OCD): Phenomenology and treatment outcome in the Pediatric OCD Treatment Study II. Journal of the American Academy of Child & Adolescent Psychiatry, 53(12), 1308 1316.

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da Silva, R. A., de Azevedo Cardoso, T., Mondin, T. C., Reyes, A. N., de Lima Bach, S., de Mattos Souza, L. D., & Jansen, K. (2017). Is narrative cognitive therapy as effective as cognitive behavior therapy in the treatment for depression in young adults? The Journal of Nervous and Mental Disease, 205(12), 918 924. Drysdale, A. T., Hartley, C. A., Pattwell, S. S., Ruberry, E. J., Somerville, L. H., Compton, S. N., & Walkup, J. T. (2014). Fear and anxiety from principle to practice: Implications for when to treat youth with anxiety disorders. Biological Psychiatry, 75, 19 20. Ehrenreich-May, J., Kennedy, S. M., Sherman, J. A., Bennett, S. M., & Barlow, D. H. (2018). Unified protocols for transdiagnostic treatment of emotional disorders in adolescents: Workbook. Oxford University Press, Programs that Work. Forehand, R., & Wierson, M. (1993). The role of developmental factors in planning behavioral interventions for children: Disruptive behavior as an example. Behavior Therapy, 24, 117 141. Fox, S., Desai, P., Schonfeld, E., Duarte, C., Fisher, P., & Albano, A.M. (2018, November). The development and preliminary validation of a launching emerging adults functioning scale (LEAF-A) to assess independence in young adults. Poster at the Association for Behavioral and Cognitive Therapies, ABCT 52nd Annual Convention, Washington D.C. Guerry, J., Hambrick, J., & Albano, A. M. (2014). In K. Ranta, A. M. La Greca, L.-J. Garcı´aLopez, & M. Marttunen (Eds.), Social anxiety and phobia in adolescents (pp. 201 223)). USA: Springer. Hartley, C. A., & Lee, F. S. (2015). Sensitive periods in affective development: Nonlinear maturation of fear learning. Neuropsychopharmacology, 40(1), 50. Hoffman, L. J., Guerry, J. D., & Albano, A. M. (2018). Launching anxiety young adults: A specialized cognitive behavioral intervention for transitional age youth. Current Psychiatry Report, 20, 25. Available from https://doi.org/10.1007/s11920-018-0888-9. Holmbeck, G. N., Colder, C., Shapera, W., Westhoven, V., Kenealy, L., & Updegrove, A. (2000). Working with adolescents: guides from developmental psychology. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive-behavioral procedure (pp. 334 385). New York: Guilford Press. Kendall, P. C., & Peterman, J. S. (2015). CBT for adolescents with anxiety: Mature yet still developing. American Journal of Psychiatry, 172, 519 530. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(7), 768. Kircanski, K., & Peris, T. S. (2015). Exposure and response prevention process predicts treatment outcome in youth with OCD. Journal of Abnormal Child Psychology, 43(3), 543 552. Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., & Leckman, J. F. (2013). Family accommodation in pediatric anxiety disorders. Depression and Anxiety, 30, 47 54. MacLeod, K. B., & Brownlie, E. (2014). Mental Health and transitions from adolescence to emerging adulthood: developmental and diversity considerations. Canadian journal of community mental health, 33(1), 77 86. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980 989. Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., & Storch, E. A. (2009). Decreased family accommodation associated with improved therapy outcomes in pediatric obsessive compulsive disorder. Journal of Consulting and Clinical Psychology, 77, 355 360. Moos, R. H., & Moos, B. S. (1994). Family environment scale manual. Palo Alto, CA: Consulting Psychologists Press.

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Pattwell, S. S., Bath, K. G., Casey, B. J., Ninan, I., & Lee, F. S. (2011). Selective earlyacquired fear memories undergo temporary suppression during adolescence. Proceedings of the National Academy of Sciences, 108(3), 1182 1187. Pattwell, S. S., Duhoux, S., Hartley, C. A., Johnson, D. C., Jing, D., Elliott, M. D., & Soliman, F. (2012). Altered fear learning across development in both mouse and human. Proceedings of the National Academy of Sciences, 109(40), 16318 16323. Peris, T. S., Benazon, N., Langley, A., Roblek, T., & Piacentini, J. (2008). Parental attitudes, beliefs, and responses to childhood obsessive compulsive disorder: The Parental Attitudes and Behaviors Scale. Child & Family Behavior Therapy, 30(3), 199 214. Peris, T. S., Caporino, N. E., O’Rourke, S., Kendall, P. C., Walkup, J. T., Albano, A. M., & Compton, S. N. (2017). Therapist reported features of exposure tasks that predict differential treatment outcomes for youth with anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 56, 1043 1052. Peris, T. S., Compton, S. N., Kendall, P. C., Birmaher, B., Sherrill, J., March, J., & Piacentini, J. (2015). Trajectories of change in youth anxiety during cognitive behavior therapy. Journal of Consulting and Clinical Psychology, 83, 239 252. Peris, T. S., & Piacentini, J. C. (2016). Helping families manage childhood OCD: Therapist guide. Oxford University Press, Programs that Work. Peris, T. S., Rozenman, M. S., Sugar, C. A., McCracken, J. T., & Piacentini, J. (2017). Targeted family intervention for complex cases of pediatric obsessive-compulsive disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56(12), 1034 1042. Peris, T. S., Sugar, C. A., Bergman, R. L., Chang, S., Langley, A., & Piacentini, J. (2012). Family factors predict treatment outcome for pediatric obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 80(2), 255. Schwartz, S. J. (2016). Turning point for a turning point: Advancing emerging adulthood theory and research. Emerging Adulthood, 4, 307 317. Available from https://doi.org/ 10.1177/2167696815624640. Walkup, J. T., Albano, A. M., Piacentini, J., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753 2766. Available from https://doi.org/10.1056/NEJMoa0804633, [published correction appears in N Engl J Med. 2013 31;368(5):490]. Weisz, J. R., & Hawley, K. M. (2002). Developmental factors in the treatment of adolescents. Journal of Consulting and Clinical Psychology, 70, 21 43.

Further reading Denizet-Lewis, B. (2017, October 11). Why are more American teenagers than ever suffering from severe anxiety?. The New York Times Magazine. Retrieved from https://www. nytimes.com/2017/10/11/magazine/why-are-more-american-teenagers-than-ever-suffering-from-severe-anxiety.html Schonfeld, E., Desai, P., Fox, S., Duarte, C., & Albano, A.M. (2018, November). Assessment of impairment in developmental tasks for emerging adults with social anxiety disorder. Poster at the Association for Behavioral and Cognitive Therapies, ABCT 52nd Annual Convention, Washington D.C. Somerville, L. H., Jones, R. M., & Casey, B. J. (2010). A time of change: Behavioral and neural correlates of adolescent sensitivity to appetitive and aversive environmental cues. Brain and Cognition, 72(1), 124 133.

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C H A P T E R

14 Involving family members in exposure therapy for children and adolescents Nicole E. Caporino Department of Psychology, American University, Washington, DC, United States

Families are often perceived as contributing to or maintaining a child’s anxiety/obsessive-compulsive symptoms, leading to efforts to integrate parents into cognitive-behavioral therapy (CBT). Although these efforts have been successful, family-based treatment has not always outperformed individual treatment—possibly because the emphasis on a wide array of family treatment targets has diluted the dose of exposure, which appears to be the most critical component of CBT (e.g., Taboas, McKay, Whiteside, & Storch, 2015). Identifying predictors and moderators of treatment outcomes can inform ways to refine or tailor interventions to improve their efficacy (e.g., Kazdin, 2007). Recent research has suggested that targeting family processes most likely to interfere with exposure (e.g., family accommodation of symptoms) enhances treatment outcomes (e.g., Peris et al., 2017). This chapter describes and summarizes research on family characteristics that have been linked to youth anxiety and are conceptually or empirically relevant to treatment outcomes. The chapter then provides practical recommendations for involving families in exposure-based treatment with the goal of maximizing gains.

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Family characteristics linked to youth anxiety and treatment outcomes Psychopathology in the family Anxiety and obsessive-compulsive disorder (OCD) run in families (e.g., Hettema, Neale, & Kendler, 2001). Children of anxious and/or depressed parents are more likely to exhibit elevated anxiety and to meet criteria for an anxiety disorder than children of parents without these disorders (e.g., Beidel & Turner, 1997; Biederman, Rosenbaum, Bolduc, Faraone, & Hirshfeld, 1991; Last, Phillips, & Statfeld, 1987; Silverman, Cerny, Nelles, & Burke, 1988; Steinhausen, Foldager, Perto, & Munk-Jørgensen, 2009; Wickramaratne & Weissman, 1998). Also, parents of children with anxiety disorders are more likely to have a history of an anxiety disorder relative to parents of children without anxiety disorders (Lieb et al., 2000; Weissman, Leckman, Merikangas, Gammon, & Prusoff, 1984). Risk of an anxiety disorder is highest when both parents have been affected by anxiety (Li, Sundquist, & Sundquist, 2008). Similarly, the rate of OCD is elevated in parents of youth with OCD relative to the general population (e.g., Lenane et al., 1990). Although research has generally not supported a link between parental psychopathology (broadly defined) and acute outcomes of pediatric OCD treatment, findings regarding the impact of family history of OCD have been mixed (Bolton, Luckie, & Steinberg, 1995; Garcia et al., 2010; Leonard & Rapoport, 1989; Mancebo et al., 2014; Torp et al., 2015; Yaryura-Tobias, Grunes, Walz, & Neziroglu, 2000). Diagnosis of OCD among first-degree relatives moderated outcomes in a National Institute of Mental Health (NIMH)-funded multimodal treatment study that tested the relative efficacy of CBT, sertraline, their combination, and pill placebo. Specifically, immediate family history of OCD was associated with a sixfold decrease in the effect of CBT monotherapy (Garcia et al., 2010). It may be that for parents who have OCD, assisting the child with CBT tasks (e.g., symptom monitoring, exposure, and response prevention) is more challenging than monitoring medication compliance. Maternal anxiety has predicted acute outcomes of family-based CBT for youth anxiety (e.g., Creswell, Willetts, Murray, Singhal, & Cooper, 2008; Settipani, O’Neil, Podell, Beidas, & Kendall, 2013). Also, many studies have demonstrated that clinical levels of parental anxiety predict less favorable outcomes of individual CBT at posttreatment (e.g., Bodden et al., 2008; Cobham, Dadds, & Spence, 1998; Cooper, Gallop, Willetts, & Creswell, 2008; Creswell et al., 2008) and at 1-year follow-up (e.g., Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008), though inconsistent findings have been reported (e.g., Compton et al., 2014; Ginsburg et al., 2011; Hudson et al., 2015). Similarly, studies that test

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parental depression or psychopathology broadly as a predictor of outcomes of youth anxiety treatment have yielded mixed findings (e.g., Berman, Weems, Silverman, & Kurtines, 2000; Crawford & Manassis, 2001; Liber et al., 2008; Southam-Gerow, Kendall, & Weersing, 2001; Victor, Bernat, Bernstein, & Layne, 2007). It may be that CBT protocols are differentially effective for minimizing the impact of parental psychopathology on treatment for youth. For example, there is some evidence that family-based CBT is more efficacious than individual CBT for youth anxiety when both parents experience anxiety at clinical levels (Kendall et al., 2008). It is also possible that parental anxiety influences CBT outcomes through mediating pathways; for example, by increasing caregiver strain, decreasing family functioning, or contributing to “toxic stress” that disrupts a child’s neural circuitry (i.e., extreme, frequent, or extended activation of the stress response without buffering from a supportive adult; Shonkoff et al., 2012). Finally, parental anxiety may decrease in response to improvements in youth anxiety. There is some evidence that trait anxiety improves for parents of youth who respond to CBT and/or medication (Keeton et al., 2013), and reductions in parental anxiety have been preceded by CBT-related reductions in youth anxiety (Settipani et al., 2013; Silverman, Kurtines, Jaccard, & Pina, 2009).

Modeling and verbal transfer of information It has been estimated that genes account for only 30% of the variance in child anxiety and OCD (Gregory & Eley, 2007). The possibility that these disorders are, in part, socially transmitted in families has led to a wealth of research on parental behaviors that may increase risk for child anxiety. Anxious modeling, for example, refers to a parent’s tendency to demonstrate anxious thoughts, feelings, and behaviors (Drake & Ginsburg, 2012), inadvertently teaching his/her child to be anxious and avoidant (e.g., Beidel & Turner, 1997; Bo¨gels & Brechman-Toussaint, 2006; Fisak & Grills-Taquechel, 2007). Experimental studies have linked parental anxious modeling to fear and avoidance in infants (e.g., de Rosnay, Cooper, Tsigara, & Murray, 2006), toddlers (Gerull & Rapee, 2002), and school-aged youth (Burstein & Ginsburg, 2010). Also, parent-reported anxious modeling has been positively associated with fear/anxiety in clinical and nonclinical samples, though discrepant findings have been reported (see reviews by Fisak & Grills-Taquechel, 2007; Wood, McLeod, Sigman, Hwang, & Chu, 2003). It has been hypothesized that anxious modeling of social inactivity/withdrawal, in particular, increases social anxiety in youth (Drake & Ginsburg, 2012).

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Parents may model anxious interpretations of ambiguous situations (i.e., threat bias) via verbal and nonverbal communication, resulting in biased information processing in youth (e.g., Barrett, Rapee, Dadds, & Ryan, 1996; Chorpita, Albano, & Barlow, 1996). For example, in a classic study, Barrett, Rapee, Dadds, and Ryan (1996) presented youth with a series of ambiguous events (e.g., “You see a group of students from another class playing a great game. As you walk over and join in, you notice that they are laughing”) and asked how they would interpret and respond to the event. Afterward, youth discussed these situations with their families and provided final responses. Results showed that anxious and oppositional children were both more likely than children without a disorder to interpret ambiguous scenarios in a threatening manner (e.g., the group of students are telling secrets about me) but whereas oppositional children chose aggressive solutions, anxious children predominantly chose avoidant solutions. After family discussions, a greater percentage of anxious children chose avoidant solutions; coding recordings of the discussions suggested that mothers’ verbal statements influenced children’s anxious responses. Perhaps due to methodological inconsistencies, not all studies have shown that family discussion enhances preference for avoidant responses (Bo¨gels, van Dongen, & Muris, 2003; Cobham & Dadds, 1999). More consistently, studies have found that mothers of anxious children, especially mothers who self-report anxiety, catastrophize (i.e., predict the worst outcome) more during conversational tasks than mothers of nonanxious children (Moore, Whaley, & Sigman, 2004; Whaley, Pinto, & Sigman, 1999).

Parental overcontrol “Parental overcontrol,” or excessive control, has been used to refer to overprotection, overregulation of activities, excessive vigilance, intrusive over-involvement, demandingness, or behaviors that restrict a child’s autonomy (i.e., low autonomy granting; Bo¨gels & Brechman-Toussaint, 2006; Masia & Morris, 1998; Rapee, 1997; Wood et al., 2003). Such behaviors are thought to encourage dependency on parents, which can lead to a lack of mastery or perceived control over the child’s own environment and has been linked to high levels of anxiety in youth (e.g., van Brakel, Muris, Bo¨gels, & Thomassen, 2006; Wood et al., 2003). Children of overcontrolling parents have fewer opportunities than peers to explore new environments, and to learn to problem-solve or otherwise cope with anxiety-provoking situations (Bo¨gels & Brechman-Toussaint, 2006; Chorpita & Barlow, 1998). Mothers of anxious compared to nonanxious children are more likely to be perceived by their children as overcontrolling (e.g., Bo¨gels & van Melick, 2004; McClure et al., 2001)

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and parental overcontrol has predicted later anxiety symptoms in children (e.g., Edwards, Rapee, & Kennedy, 2010) as well as anxiety disorders in adolescents/young adults (Beesdo, Pine, Lieb, & Wittchen, 2010). Among the subdimensions of overcontrol, autonomy granting and over-involvement appear to be most strongly linked to child anxiety (e.g., Hughes, Hedtke, & Kendall, 2008). Overcontrol has not consistently been associated with parental anxiety but has been associated with several child characteristics: female gender, higher socioeconomic status, and school age (van der Bruggen, Stams, & Bo¨gels, 2008). Youth whose families show greater behavior control (e.g., who regulate and structure the behavior of the child) have exhibited less anxiety symptom reduction in family-based CBT (Settipani et al., 2013), though change in behavior control has not preceded treatment-related changes in youth anxiety (Settipani et al., 2013; Wijsbroek, Hale, Raaijmakers, & Meeus, 2011). It appears that targeting excessive affective involvement, however, can enhance treatment outcomes; reductions in family affective involvement between pre- and posttreatment have predicted reductions in clinician-rated child anxiety from posttreatment to 1-year follow-up (Settipani et al., 2013). Psychological control Some researchers have distinguished psychological control from behavior control. Psychological control refers to coercive, passive aggressive, and intrusive strategies for manipulating youths’ thoughts, feelings, and activities (Barber, 1996; De Man, 1986). Whereas behavioral control involves influencing behavior directly (e.g., by establishing rules and insisting they be followed), psychological control often involves influencing behavior indirectly (e.g., by inducing guilt or withdrawing affection); both are in contrast to autonomy granting. Psychological control is thought to limit youths’ ability to manage their emotions (Barber, 1996) and decrease their perceived control over their environment, leading to feelings of helplessness (Chorpita, Brown, & Barlow, 1998). Parental psychological control has been associated with poor self-esteem and internalizing problems in youths (Barber, 1996; Nanda, Kotchick, & Grover, 2012) and has predicted increases in adolescents’ anxiety over 1 year (Schleider, Ve´lez, Krause, & Gillham, 2014). Parental psychological control may influence youth anxiety through the development of negative cognitive/attributional styles (McGinn, Cukor, & Sanderson, 2005; Schleider et al., 2014). In a study of family-based CBT for separation, social, and generalized anxiety in youth (Kendall et al., 2008), reductions in maternal psychological control preceded reductions in clinician-rated youth anxiety (suggesting that it is useful to target psychological control in treatment; Settipani et al., 2013).

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Family accommodation Family accommodation refers to actions (or deliberate inaction) by family members to help prevent or alleviate anxiety/OCD symptoms in the affected individual. In the youth literature, “family accommodation” has been used synonymously with “parental accommodation,” though there is evidence that siblings also accommodate symptoms (e.g., Barrett, Rasmussen, & Healy, 2000). Family accommodation includes directly participating in or facilitating symptoms (e.g., by providing objects necessary for a compulsion), yielding to the child’s symptomrelated demands (e.g., following a certain routine in order to minimize anxiety), providing excessive reassurance to the child (e.g., answering questions repeatedly), assisting with or complete tasks (e.g., homework) for the child, or decreasing the child’s responsibility (e.g., limiting attempts at discipline) because anxiety or obsessive-compulsive symptoms interfere with his/her ability to meet expectations (e.g., Storch et al., 2007). Family accommodation was first studied in the context of OCD (e.g., Calvocoressi, Lewis, Harris, & Trufan, 1995; Calvocoressi et al., 1999). Examples of accommodation of pediatric OCD symptoms include physically helping to wash/clean, wearing sterile gloves while preparing food, opening doors or turning on light switches, driving same exact route to and from school, and not entering the child’s room or touching his/her personal belongings (Farrell & Barrett, 2007). Depending on the specific form of accommodation, burden on families can range from mild (e.g., reassuring a child that he will not contract HIV by touching something red) to extreme (e.g., not transporting groceries in the family car perceived by the child to be contaminated). Nearly all parents of clinic-referred youth with OCD endorse some form of accommodation, with the majority reporting that they accommodate on a daily basis (e.g., Flessner et al., 2011; Peris, Benazon, Langley, Roblek, & Piacentini, 2008; Peris, Bergman, Langley, Chang, et al., 2008). The accommodation of contamination symptoms appears to be most common, possibly because it is easier for parents to recognize (and report) than the accommodation of other OCD symptom types (Flessner, Freeman, et al., 2011; Stewart et al., 2008; Wu, Lewin, Murphy, Geffken, & Storch, 2014). More recently, the study of family accommodation has been extended to non-OCD anxiety disorders (e.g., Benito et al., 2015; Lebowitz, Panza, Su, & Bloch, 2012). Nearly all parents of youth presenting for treatment of anxiety disorders engage in some form of accommodation, commonly providing reassurance about a feared situation, facilitating avoidance of anxiety-provoking situations, and modifying the family routine due to the child’s anxiety (e.g., Benito et al., 2015; Lebowitz et al., 2012). Examples of such accommodation include picking up a child early from

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a sleepover, getting a child out of a school assignment or performance (e.g., play, spelling bee), letting a child avoid a birthday party, or allowing a child to sleep in a parent’s bed (Thompson-Hollands, Kerns, Pincus, & Comer, 2014). As with OCD, the level of effort required to accommodate child anxiety symptoms can range from minimal (e.g., ordering for a socially anxious child at a restaurant) to extreme (e.g., securing employment as a substitute teacher at a separation anxious child’s school). There has been some suggestion that accommodation is highest for youth with generalized anxiety disorder and separation anxiety disorder, though not all studies have supported differences by diagnosis (Benito et al., 2015). Interestingly, family accommodation of anxiety has been negatively correlated with youth levels of salivary oxytocin, which is implicated in the regulation of anxiety and the modulation of close interpersonal behaviors (Lebowitz et al., 2016). Family accommodation is thought to maintain or exacerbate the youth’s disorder by facilitating avoidance of symptom triggers and, in the case of OCD, negatively reinforcing compulsions. By preventing or reducing anxiety in a fashion similar to ritual engagement, family accommodation limits a child’s opportunities to experience habituation and to learn that feared outcomes are not likely to occur (Storch et al., 2007)—and is thus, counter to the goals of CBT. Also, accommodating a child’s symptoms diminishes the aversive consequences of the anxiety disorder/OCD (e.g., interference with preferred activities), perhaps reducing motivation for treatment (Caporino et al., 2012). In fact, family accommodation may explain children’s tendency to underreport impairment relative to parent ratings (Storch et al., 2011). It may be that families are accommodating symptoms to the extent that children do not perceive themselves to be impaired; parents, more so than children, are assuming the burden of the OCD. Parents of youth with OCD have endorsed engaging in accommodation in order to minimize the child’s distress, to reduce the time spent on rituals, to keep the OCD from interfering with school and/or social activities, and because it would be difficult for the family to get through their day otherwise. Parents’ accommodating behaviors may also be negatively reinforced by the reduction in distress that they experience when their child is anxious (Caporino et al., 2012). Clinical observations and preliminary data suggest that at least a subset of parents enter treatment with awareness that family accommodation is likely helping the child in the short but not the long term (Caporino, Morgan, Phares, Murphy, & Storch, 2010). Consistent with this idea, family accommodation of OCD has been repeatedly linked to symptom severity (see meta-analyses by Strauss, Hale, & Stobie, 2015; Wu et al., 2016) and parent-rated impairment (e.g., Caporino et al., 2012; Storch et al., 2011). Symptom severity has also been significantly related to the accommodation

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of anxiety symptoms (e.g., Lebowitz et al., 2013), especially when rated by clinicians (Benito et al., 2015). Longitudinal data are needed to determine the extent to which family accommodation leads to more severe symptoms, as it is also possible that youth with severe symptoms are more likely to elicit accommodation from family members. In addition to symptom severity and impairment, a number of child characteristics have been examined in relation to family accommodation. Across OCD and anxiety disorders, comorbid internalizing problems (e.g., depressive disorders) in youth have been associated with higher levels of accommodation (Benito et al., 2015; Storch et al., 2014; Wu et al., 2014). Youth externalizing problems have been positively associated with family accommodation of OCD but not anxiety symptoms (e.g., Benito et al., 2015; Caporino et al., 2012; Morgan et al., 2013; Storch et al., 2007, 2015; Wu et al., 2014), suggesting that tantrums and other disruptive behavior might punish parents’ efforts to refrain from accommodating OCD. A couple of studies have found high levels of accommodation by parents of youth with OCD who have relatively poor insight or awareness/understanding of their symptoms (Bipeta, Yerramilli, Pingali, Karredla, & Ali, 2013; Storch et al., 2008). Parents with elevated trait anxiety exhibit higher levels of accommodation (Flessner et al., 2011; Frank et al., 2014; Lebowitz et al, 2012; Merlo, Lehmkuhl, Geffken, & Storch, 2009; Peris, Benazon, Langley, Roblek et al., 2008; Peris, Bergman, Langley, Chang, et al., 2008), though this relationship might be specific to mothers (vs fathers; Futh, Simonds, & Micali, 2012; Thompson-Hollands et al., 2014). Family accommodation has also been associated with parental anxiety about the child’s OCD (Storch et al., 2009). Findings regarding the relationship between family accommodation and parental depression have been mixed (e.g., Benito et al., 2015; Futh et al., 2012; Thompson-Hollands et al., 2014). Although family accommodation may serve a function for families in the short term, it is typically experienced as burdensome by parents (e.g., Futh et al., 2012; Lebowitz et al., 2013). Parents of youth who have not responded to first-line treatments for OCD report particularly high stress related to providing accommodation (Storch, Merlo, et al., 2008). The majority of parents of clinic-referred youth with anxiety disorders endorse distress when accommodating and negative consequences of refraining from accommodating, such as the child’s anxiety escalating or the child becoming angry and “abusive” (Lebowitz et al., 2013). Taken together, available data suggest that many parents would prefer to withhold accommodation but often do not believe there is an alternative or do not feel capable of disengaging from their child’s symptoms.

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Family accommodation is considered to interfere with exposure that would otherwise occur between treatment sessions, limiting symptom reduction in CBT. Indeed, family accommodation has emerged as a consistent predictor of relatively poor response to individual exposurebased treatment for pediatric OCD (see review by Caporino & Storch, 2016), delivered alone or in combination with a selective serotonin reuptake inhibitor (Marrs Garcia et al., 2010). Families that show greater change in accommodation over the course of treatment have better outcomes (Merlo et al., 2009) and reduction in family accommodation has temporally preceded improvement in OCD symptoms (strengthening the rationale for focusing on family accommodation in treatment; Piacentini et al., 2011). Family-inclusive treatments (for youth or adults) that target family accommodation of OCD symptoms have been associated with larger effects on functioning than treatments that do not specifically address accommodation (Thompson-Hollands, Edson, Tompson, & Comer, 2014). Data on Positive Family Interaction Therapy (PFIT), a six-session family therapy module used with exposure and response prevention (ERP), are particularly compelling (Peris & Piacentini, 2016). PFIT, which targets family accommodation (among other familial responses to OCD that are known to attenuate treatment response), has yielded significantly greater reductions in functional impairment than standard ERP, with changes in accommodation mediating treatment response (Peris, Rozenman, Sugar, McCracken, & Piacentini, 2017). Intervention with a focus on family accommodation has also shown promise as standalone intervention for pediatric OCD, appropriate for youth refusing treatment (Lebowitz, 2013); further research is in progress. Although family accommodation has been studied less extensively in the context of CBT for anxiety disorders, there is preliminary evidence from an open trial that it is significantly associated with treatment response, and that reduction in parent-rated accommodation is significantly associated with the severity of youth’s posttreatment anxiety, even when controlling for pretreatment youth anxiety (Kagan, Peterman, Carper, & Kendall, 2016). Because dose of exposure has been related to outcomes of individual CBT for anxiety in youth (e.g., Peris et al., 2017) and family accommodation could be conceptualized as inversely related to the between-session dose of exposure, Kagan et al.’s (2016) findings are likely to be replicated in other samples. As with pediatric OCD, a standalone parent-based intervention that focuses on withdrawing accommodation has potential efficacy for youth who decline treatment (Lebowitz, Homer, Hermes, & Scahill, 2013). A clinical trial to test this format is underway.

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Rescue behavior In line with studies of overprotection/overcontrol and family accommodation, research has examined latency of a rescue response, or how long a parent waits to intervene on a child’s behalf in an anxietyprovoking situation. Aschenbrand and Kendall (2012) asked mothers to listen to a recording in which a child was either described as anxious or described in a neutral manner. They were then asked to listen to a conversation between the child and her mother, in which the child exhibited escalating anxiety, and were instructed to press a button when they thought the mother in the recording should do as her child asked (i.e., allow/help her to avoid or escape the situation). Interestingly, parents of clinically anxious children showed the same latency to rescue the child regardless of whether or not they were told that the child in the recording is, by nature, highly anxious (Aschenbrand & Kendall, 2012). Parents of nonanxious children, however, showed greater latency (i.e., waited longer) to rescue the child when told he/she was trait-anxious. One explanation for this pattern of findings is that parents of nonanxious children see value in encouraging approach behavior in a child who generally struggles with anxiety, and are more likely than parents of anxious children to adapt their behavior accordingly.

Parental cognitions about child anxiety Parental cognitions predict parenting behavior (Bugenthal & Johnson, 2000; Murphey, 1992). Parents of children with anxiety disorders/OCD report more negative expectations of their child’s ability (e.g., skill, coping ability) than do parents of children without these disorders (e.g., Barrett, Shortt, & Healy, 2002; Micco & Ehrenreich, 2008). Further, parents’ negative beliefs about their child’s disposition, coping ability, and potential for success have been linked to children’s low expectations for coping and higher levels of anxiety (Wheatcroft & Creswell, 2007). In a recent study, parent beliefs about anxiety were related to accommodation of youth anxiety, such that mothers who reported more strongly believing that anxiety is harmful for children were more likely to report that they would allow their child to avoid feared situations (Settipani & Kendall, 2017). Finally, beliefs that OCD is within the child’s control (attributions of blame and personal responsibility) may lead otherwise loving parents to respond to symptoms with open anger and have predicted relatively poor treatment response (Peris, Benazon, Langley, Roblek et al., 2008; Peris, Bergman, Langley, Chang, et al., 2008; Peris et al., 2012).

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Family functioning Studies have also evaluated the impact of general family functioning on youth anxiety and treatment outcomes. Family functioning is a broad term that may encompass task accomplishment (the process by which the family achieves goals), role performance (e.g., how family members understand what is expected), affective involvement (the degree and quality of family members’ interest in one another), control (the process by which family members influence one another), values and norms (e.g., how consistent they are), and/or communication/affective expression (how emotions are expressed; Skinner, Steinhauer, & SantaBarbara, 1995). Families may also be characterized along the dimensions of cohesion (i.e., emotional bonding among family members or the extent to which they support and encourage each other) and adaptability (i.e., the ability of the family to change in structure, role relationships, and relationship rules in response to stress) (Olson, Russell, & Sprenkle, 1983). There is some evidence that very high or very low levels of cohesion and adaptability are associated with anxiety (e.g., Bernstein, Warren, Massie, & Thuras, 1999; Peleg-Popko & Dar, 2001; Stark, Humphrey, Crook, & Lewis, 1990; Teichman & Ziv, 1998) and improvements in adaptability may buffer against increases in girls’ internalizing problems as they transition to adulthood (Moreira & Telzer, 2015). Poor family functioning has been linked to diminished response to CBT for pediatric OCD. Higher levels of family dysfunction predicted poorer 18-month follow-up outcomes of individual and group cognitive-behavioral family therapy for pediatric OCD (Barrett, Farrell, Dadds, & Boulter, 2005). In another study, families with higher levels of parental blame and family conflict, and lower levels of family cohesion, were less likely to have a child who responded to family-focused CBT, even after adjusting for baseline symptom severity (Peris et al., 2012). Among families with relatively high levels of functioning on all three indicators, youth had a 93% response rate. Among families with relatively poor functioning on all three indicators, youth had a 10% response rate. Also, high maternal expressed emotion (i.e., attitudes of high criticism, hostility, and/or emotional over-involvement; Vaughn & Leff, 1985) has significantly predicted poor outcomes of CBT (Peris et al., 2012). However, family functioning and expressed emotion specifically have not predicted outcomes in multimodal treatment studies (Garcia et al., 2010; Przeworski et al., 2012; Wever & Rey, 1997). Several studies have suggested that strong family functioning facilitates positive response to CBT for anxiety disorders in youth (Barrett et al., 2005; Crawford & Manassis, 2001; Victor et al., 2007). Although family functioning did not predict or moderate acute outcomes in the

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largest multimodal treatment trial (Compton et al., 2014), parentreported family dysfunction improved for treatment responders (Keeton et al., 2013). Also, parental report of stronger family functioning at pretreatment predicted stable remission of anxiety disorders across a 4-year period, beginning 4 12 years after treatment was initiated (Ginsburg et al., 2014; Ginsburg, Schleider, Tein, & Drake, 2018).

Caregiver strain/family burden Caregiver strain refers to negative thoughts and feelings (e.g., embarrassment, guilt, worry), demands on time, fatigue, financial strain, sacrifice, and disruptions in relationships or routines associated with caring for someone with mental illness (Brannan, Heflinger, & Bickman, 1997; Montgomery, Gonyea, & Hooyman, 1985; Platt, 1985). Parents of youth with OCD/anxiety frequently endorse substantial emotional burden (e.g., de Abreu Ramos-Cerqueira, Torres, Torresan, Negreiros, & Vitorino, 2008; Peris, Bergman, et al., 2008), which increases with symptom severity, impairment, and family accommodation (e.g., Storch et al., 2009). High levels of caregiver strain have predicted less favorable outcomes of CBT and/or medication for anxiety disorders in youth (e.g., Compton et al., 2004; Crawford & Manassis, 2001). Interestingly, caregiver strain/family burden appeared to decrease after treatment was initiated in the largest multimodal treatment trial, regardless of the child’s symptom improvement (Keeton et al., 2013). Families with parents who exhibited greater psychopathology at pretreatment showed more improvement in caregiver strain and family functioning, which in turn, predicted greater youth anxiety reductions (Schleider et al., 2015).

Practical recommendations Attending to family context during assessment Family involvement should begin with assessment that includes all relevant caregivers. Multiinformant assessment is critical in practice with youth, as informant discrepancies are common. A clinician should let families know that it is common to have different perspectives on a child’s difficulties, especially since his/her behavior might differ across contexts, and that each person’s perspective is of interest. Agreement between parents and youth is generally lower for adolescents than for young children, and for reports of internalizing versus externalizing problems (e.g., De Los Reyes & Kazdin, 2005). Maternal anxiety and depression appear to bias mothers’ ratings of child psychopathology relative to other informants (i.e., youth, teachers, independent observers; e.g., Moreno, Silverman, Saavedra, & Phares, 2008; Niditch & Varela, 2011).

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Parents who experience anxiety might interpret behavioral difficulties through that lens (e.g., attributing child difficulties to anxious avoidance rather than defiance) and depression appears to contribute to more negative appraisals of child behavior in general (e.g., Chi & Hinshaw, 2002). Clinicians should attend to possible reasons for informant discrepancies (e.g., lack of motivation among youth) and probe for concrete examples to support each individual’s report. Behavioral observations (e.g., how comfortably a child separates from his/her parents to be interviewed) are also valuable, especially in light of research suggesting that parents of youth with anxiety/OCD lack confidence in their child’s coping ability (Barrett et al., 2002). Providing opportunities for youth to show what they can handle may allow for a more accurate evaluation of their anxiety than taking cues from family members, whose expectations may have been shaped by past avoidance. For example, the parents of an 11-year-old child warned that she had never separated from them to meet with any of her three prior therapists. The clinician nevertheless prompted the family to separate during the first visit so that she could interview the child alone, at which point the parents appeared highly uncomfortable but the child cooperated. Much to the family’s surprise, the child spoke to the clinician alone for an hour without visible distress. In addition to recruiting family members to report on youth symptoms, clinicians should inquire about parent/family responses to the anxiety/OCD symptoms in order to tailor treatment recommendations. What strategies have the parents tried to help with the anxiety/OCD and what happened as a result? How often does the family accommodate symptoms and at what cost to family members? What does accommodation of the child’s specific symptoms look like? How does the child react when the family tries to refrain from accommodating? Such conversations can be guided by clinician- or parent-rated measures: the revised Family Accommodation Scale (Calvocoressi et al., 1999), the Family Accommodation Scale Parent Report (Flessner et al., 2011), and/or or the Parental Attitudes and Behaviors Scale (Peris, Benazon, Langley, Roblek et al., 2008; Peris, Bergman, Langley, Chang, et al., 2008) for OCD; and the Pediatric Accommodation Scale (Benito et al., 2015), the Family Accommodation Scale Anxiety (Lebowitz et al., 2013), or the Family Accommodation Checklist and Interference Scale (Thompson-Hollands et al., 2014) for anxiety. Although parent-report measures are more feasible to administer when time is limited, research has suggested some benefit to clinician assessment (Benito et al., 2015), possibly because parents who experience anxiety have difficulty recognizing specific forms of accommodation without prompting. In addition to informing treatment planning, assessing family accommodation might help resolve informant discrepancies, as children may report relatively little distress or impairment when families are engaging in high levels of accommodation.

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Clinicians should also attend to parent beliefs that might drive overprotection, accommodation, criticism of the child, or other therapyinterfering behavior. For example, do parents believe that anxious children need to be protected? Do they expect that their child will be traumatized or fall apart if pushed to do something uncomfortable? Do they believe that their child engages in symptom behaviors on purpose? There are questionnaires for identifying such beliefs (Peris, Benazon, Langley, Roblek et al., 2008; Peris, Bergman, Langley, Chang, et al., 2008; Wolk et al., 2016), which may also become evident through observation and discussion early in treatment. Other areas for assessment, whether formal or informal, include family history of psychopathology—which might assist with decisions about the optimal treatment format and the benefit of adjunctive services. For example, research has suggested that when both parents exhibit elevated anxiety, family-based CBT (which involves the family’s active participation in all sessions) is more efficacious for a child with separation, social, and/or generalized anxiety than individual CBT (Kendall et al., 2008). Also, CBT alone may be less likely to yield significant symptom reductions in youth with an immediate family history of OCD (Garcia et al., 2010). Attending to general family functioning can also be valuable for planning. For example, it may not be critical for both parents to attend sessions when there are scheduling constraints if the family exhibits shared values and strong communication. Asking about caregiver strain helps to ensure that families feel heard and validated (setting the stage for behavior change) and could alert the clinician to the need for early problem solving (e.g., to ensure session attendance) and/or referrals for outside support. Finally, asking about family strengths may help to set a positive tone, improve treatment expectations, and suggest ways that clinicians can capitalize on what the family already does well. In general, clinicians should employ multiple methods of assessment and avoid relying on any one indicator when making treatment decisions. Also, family involvement in assessment should be ongoing. Even in individual treatment, families can be helpful in developing the fear hierarchy and monitoring a child’s treatment progress. Staying alert to family processes and characteristics that have been linked to youth anxiety and/or treatment outcomes (e.g., parental modeling of threat interpretations and anxious avoidance) will allow for teachable moments throughout treatment.

Choosing a treatment format Nearly all protocols for treating OCD and anxiety in youth involve parents to some degree. In individual treatment, there are often a couple

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of dedicated parent sessions and families are otherwise included as needed (e.g., Kendall & Hedtke, 2006; March & Mulle, 1998). Interventions for young children typically provide more structure for family involvement (e.g., Comer et al., 2012; Freeman et al., 2008). Given research suggesting that they are equally efficacious, on average, individual or family-based CBT for youth anxiety should be selected on a case-by-case basis in consideration of results of a family assessment, the youth’s developmental level and motivation for change, and any logistical constraints. Adolescents, for example, might benefit from having more ownership over their treatment given their developmental push for autonomy. Even when session time with families is minimal, there are many ways to keep them in the loop so that they can facilitate progress. For example, the clinician might take 10 minutes the end of each session to have a school-aged child teach his/her parent(s) the concepts and skills learned that day. This activity allows the therapist to assess the child’s understanding and mastery in addition to communicating session content to parents so that they can prompt and reinforce coping at home. The clinician might also suggest that motivated parents read books that parallel or complement treatment (e.g., Chansky, 2004; Kendall, Podell, & Gosch, 2010). Regular parent participation in sessions (i.e., family-based treatment) may offer several advantages. The “transfer-of-control” model of treatment (Silverman, Ginsburg, & Kurtines, 1995), designed to address parental overcontrol, can be employed to gradually transfer knowledge, skills, and methods from the therapist to the parent and then from the parent to the child. At the start of treatment, the therapist acts as “coach” to both the parents and child and then gradually “hands over” some of the coaching responsibilities to the parents, teaching them constructive ways to support their child as he/she learns to cope independently (Howard, Chu, Krain, Marrs-Garcia, & Kendall, 2000). Research on family-based CBT has shown this transfer-of-control approach to contribute to improvements in youth’s global functioning (Khanna & Kendall, 2009). More specifically, regular parent participation in sessions may facilitate understanding of treatment principles, help parents become effective coping models for their children, reduce family accommodation and other interactions that influence anxiety, encourage optimal effort on the part of the child during in-session exposure tasks, promote the generalization of skills learned in session to outside settings, and provide secondary benefits to parents who experience anxiety themselves (e.g., Freeman et al., 2003; Howard et al., 2000). Exposure tasks designed to target the child’s symptoms might serve as exposure for parents who are inclined to rescue their child from distressing situations.

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By observing therapist-led exposure, parents’ may habituate to the anxiety they experience upon witnessing their child’s discomfort and learn that the child can tolerate anxiety—perhaps violating expectancies that he/she would fall apart or be traumatized. Participating in the exposure task alongside the child could lead to improvements in symptoms that parents share with their children (e.g., contamination fears), increasing the likelihood that parents will refrain from accommodation and encourage the child to complete exposure assignments at home. Finally, the therapist can model for parents how to convey confidence that the child can handle the exposure (even when they feel uncertain!) and how to respond to efforts to solicit accommodation (e.g., shrugging when the child seeks reassurance that the feared outcome will not occur). Balancing the alliance with family members who may have different perspectives and preferences (e.g., by not “talking over” the child, not undermining the parent’s authority while recommending change) can be challenging when everyone is in the same room; although maintaining transparency is generally advised, it is okay to reserve portions of any session to meet alone with either the child or parents to communicate potentially sensitive information privately. In the case of OCD, there is evidence that family-focused treatment is superior to standard treatment for cases complicated by poor family functioning (Peris et al., 2017). PFIT is a six-session adjunctive intervention that focuses on helping families better understand how to respond to a child’s OCD symptoms and targets patterns of interaction that may interfere with exposure-based treatment. It is intended to be used flexibly, with the sequence of sessions tailored to the family’s needs to maximize participation from all caregivers. For struggling families who feel desperate for some immediate relief, intensive treatment programs (which involve daily sessions for 3 weeks) might be worthwhile. Although intensive treatment is comparable in efficacy to the standard format of family-based treatment (i.e., weekly sessions delivered over several months), it appears to yield greater reductions in family accommodation (Storch et al., 2007). When planning for treatment, clinicians should consider all relevant caregivers (e.g., grandparents) and siblings, as they might accommodate the affected child’s symptoms or even trigger them (e.g., if the child perceives them to be contaminated). It might be beneficial to include them in exposure in addition to helping them better understand their relative’s OCD/anxiety. Because incorporating family members in treatment might bring up a range of issues, clinicians should redirect conversations as needed to maintain the focus of therapy on the child’s anxiety. It is reasonable to discuss issues such as marital discord or a parent’s psychopathology to the extent that they interfere with the child’s treatment, but families should be referred to other providers if more focused intervention is needed. III. Developmental considerations

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Orienting families to treatment To secure families’ commitment to change, it is important to orient them to treatment. Parents may not realize upon seeking services that they will be integral to the change process. Clinicians should highlight the importance of parents’ consistent attendance and explain that family-focused treatment may require them to change their own behavior as they learn to respond to the child’s symptoms in adaptive ways. These conversations may bring up feelings of guilt for parents as they realize how family dynamics contribute to the child’s disorder. It is essential to reassure parents that they did not cause their child’s anxiety/OCD; rather, their child requires a different response than do most children. Instead of presenting parent behavior as part of the problem, emphasize it as part of the solution. Additionally, the clinician should manage the family’s expectations for treatment by explaining that change will be gradual and that setbacks are normal. Research has suggested that most CBT-related symptom improvement happens after exposure is introduced (Kendall et al., 1997; Peris et al., 2015).

Addressing family responses to obsessive-compulsive disorder/anxiety symptoms Processing emotions Addressing family responses to OCD/anxiety symptoms is at the core of effective family-focused treatment. Before families can alter their behavior, they may need time to process their reactions to the child’s disorder in session. Parents often feel that they have “reached their limit” by the time treatment is initiated. Clinicians should normalize feelings of helplessness, fear, frustration, resentment, or disappointment (which may also help to alleviate any accompanying guilt) and instill hope. Withdrawing family accommodation Psychoeducation about family accommodation (e.g., how it maintains or exacerbates anxiety in the long term) should be provided to secure families’ buy-in for discontinuing it. Here is sample language for introducing family accommodation: Family members typically find themselves getting involved in a child’s symptoms. They may participate in the child’s rituals, help the child to avoid situations that cause anxiety, or reassure the child over and over that something he fears isn’t going to happen. Parents might also change their expectations or routines because of the child’s anxiety. For example, parents of a child who is preoccupied with dirt and germs might find themselves buying him extra hand sanitizer, giving into requests that they wear gloves or wash their hands frequently, or reassuring the child repeatedly that he is not going to get ill. They might also

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excuse the child from chores, like taking out the garbage, because his concern with dirt and germs gets in the way. We call this “accommodation.” Does this sound like your family? In what ways do you accommodate your child’s symptoms? In the short-term, accommodation makes a lot of sense. It can help your child get through the day or feel less distressed. And it’s normal for parents to want to rescue their child from distress! But we have found that accommodation actually maintains a child’s symptoms or makes them stronger in the long run. When something triggers the child’s symptoms (for example, he touches a doorknob in public) and his parents accommodate them (by providing hand sanitizer), he feels some immediate relief. But he doesn’t get to see that what he fears (getting very sick) typically doesn’t happen and that his anxiety would eventually come down without help from anybody. And the next time he encounters the trigger (the doorknob), the anxiety goes up again. When you add up the number of times his anxiety peaks over the day or week, he’s spending a lot of time feeling pretty anxious and he needs assistance to function well. In fact, family members often find themselves having to do more and more to make the child feel okay.

In PFIT (Peris & Piacentini, 2016), families work together to identify ways that the child’s symptoms are accommodated. Parents then rate how difficult it would be for them to refrain from accommodating each symptom or in each circumstance listed, as well as how much discomfort they think it would cause their child. Children later provide their own ratings, allowing the clinician to compare differences. Often, parents report greater anxiety about refraining from accommodation than youth anticipate experiencing as a result. The “joint hierarchy” can be used to provide anxious parents with evidence that children can often handle more than adults expect of them. The following table provides sample exposure tasks for targeting accommodation of contamination symptoms.

Parent rating

Exposure Instead of reassuring child, parent ignores question, shrugs shoulders, or says “What do you think?” or “Maybe yes, maybe no” Parent refrains from opening doors for child Parent provides a set amount of hand sanitizer each week for child to ration Parent does not excuse child from cleaning up after pet/taking out trash/washing dishes Parent refrains from wearing gloves before preparing child’s food Parent washes child’s clothes with family members’ laundry rather than separately Parent refrains from wiping child during toileting

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Throughout the exposure phase of treatment, the clinician should work with the family to gradually withdraw accommodation as corresponding symptoms are targeted with in-session exposure tasks and parallel homework assignments. Eliminating accommodation all at once is generally not recommended, as it is likely to be unsuccessful and overwhelming for the child and his/her parents (e.g., Storch, 2017). At the same time, clinicians should not hesitate to coach parents to move at a pace sufficient to ensure an optimal dose of exposure between sessions. When discussing accommodation, the clinician should be careful not to inadvertently make family members feel that they have been doing something “wrong.” Clinicians can normalize parents’ instinct to protect their child from distress and acknowledge that accommodation has been functional for the family, as it typically reduces distress and impairment in the short term. Many parents will already be aware that accommodation works against their child’s mental health in the long term but engage in accommodation because they do not feel capable of restricting accommodation or do not believe there is an alternative. Disengaging from symptoms might be particularly challenging for parents who are highly emphatic (a “risky strength”) and very-present focused (Caporino et al., 2012). For these parents, motivational interviewing strategies (Miller & Rollnick, 2012) might be useful for resolving ambivalence about changing their own behavior due to conflict between short- and long-term contingencies. For example, the clinician might engage parents in a cost benefit analysis (e.g., have them briefly list the problems created by the disorder alongside any reasons to accommodate symptoms) and validate the mixed feelings that come with making changes. Also, it might ease parents’ anxiety about withdrawing accommodation to have a generally compliant child give verbal permission for parents to take his/her side over that of the “OCD/ anxiety monster” (or whatever language the child uses to externalize the disorder) during heated moments. (“Your parents are on your team, so when OCD tries to boss you around and make you get them to wear gloves to cook your food, your parents are not going to give in. Is that okay with you?”) At a minimum, the clinician should inform the child of how the parents will respond to OCD symptoms and make sure he/ she understands the rationale for this approach. Many families endorse engaging in accommodation because it would be difficult to get through the day otherwise (Caporino et al., 2010). For example, families with multiple children might have difficulty leaving the house to get everyone to school on time if conflict ensues upon resisting the anxious child’s symptom-related demand. These families might benefit from assistance in problem-solving around these obstacles in advance of attempting therapy assignments at home. The clinician should help the family brainstorm possible solutions (e.g., beginning to

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target morning routines on weekends or breaks; making alternate arrangements for their other children to get to school while focused on treatment), suspending judgment in the process. Families can then be prompted to evaluate solutions with attention to their short- and longterm consequences for everyone involved, and select one solution to implement. The clinician should be sure to check on the family’s progress at the earliest opportunity and prompt them to try another solution, if needed. This exercise increases the likelihood that families will follow through with exposure assignments and other treatment recommendations (e.g., by securing verbal commitment, removing barriers) while also teaching problem-solving skills that can be applied in other contexts. Research on PFIT suggests that problem-solving training might be especially useful to families characterized by high levels of blame and conflict, and low levels of cohesion (Piacentini et al., 2011; Peris et al., 2017; Peris & Piacentini, 2016). When parents have difficulty withdrawing accommodation despite appearing to understand and buy the rationale for this approach, it might be helpful to devote some session time to examining and restructuring cognitions that interfere with the following treatment recommendations. In a case of school avoidance, for example, the mother appeared to have significant difficulty placing expectations on her child to approach/endure even mildly distressing situations, despite insession successes. Meeting with the mother alone to complete a thought record revealed that when her child was distressed, the mother had automatic thoughts that she was like her father, who had abused her during childhood. After teaching her to challenge these thoughts, she was able to move forward with the treatment plan. Clinicians might also consider teaching distress tolerance techniques (e.g., distraction) to parents who have difficulty disengaging from their child’s symptoms or who are reactive during difficult episodes. Details on the use of these techniques and relevant handouts can be found in dialectical behavior therapy manuals (e.g., Linehan, 2014). Mindfulness practices can also be recommended to enhance parent’s emotion regulation by reducing cortisol levels (Creswell, Pacilio, Lindsay, & Brown, 2014). Managing difficult episodes Refraining from accommodation (and encouraging exposure) at home might result in conflict as the child’s distress escalates. Children should be encouraged to use their feelings thermometer/Subjective Units of Distress Scale to appropriately communicate the intensity of their distress, decreasing the likelihood of negative family interactions. PFIT encourages families who are prone to conflict to take a “time out” and walk away from the child with OCD during particularly heated episodes (Peris & Piacentini, 2016). A time out allows the child space to

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test out or practice strategies taught in treatment, thereby preventing a “power struggle” during which parents are pushing the use of these strategies and the child is rejecting them. The time out also allows parents’ space to manage their own emotions more effectively and to model adaptive coping strategies of their own. Clinicians may prompt this type of time out in session. For example, when a child who feared dying from ingesting toxins became highly distressed during an exposure task that involved putting lotion on her face, she started to scream and curse at her mother. The mother reacted, in turn, at which point the clinician said “I’m going to suggest that your mom step out of the room for a minute to give you space to pull yourself together. She’ll come back when you’re ready.” Once the mother’s attention was removed, the child was able to regulate her emotion fairly quickly and the exposure task was continued. (To keep from negatively reinforcing the child’s protest behavior, the clinician was careful not to end the session before the exposure task was completed.) It is helpful to explain to families that when children experience intense anxious arousal, their ability to process information accurately is compromised; thus, it is not an ideal time to try to reason with them or insist that they use skills learned in treatment. These conversations can be revisited after everyone has calmed down. What should families do when walking away is not sufficient for deescalating conflict around anxiety symptoms? A differential attention strategy, which involves ignoring (extinguishing) undesirable behavior while attending to (reinforcing) desirable alternatives, is recommended when a child tries to further engage the parents. That is, parents should ignore any inappropriate behavior (e.g., foul language, threats) that it is not dangerous and praise or otherwise reward efforts at adaptive coping. To address any aggressive behavior, the clinician should help the parents identify and consistently implement fair consequences (and may need to discuss a safety plan with the family). Many families are reluctant to discipline youth for aggression or other behavior that they would typically treat as unacceptable when they recognize that it is part of a sequence that began with anxiety. Clinicians may wish to highlight for the family the distinction between punishing anxiety (which is not recommended) and punishing subsequent aggressive behaviors. It is helpful to explain to parents that it is often necessary to change the contingencies around a child’s behaviors to ensure that he/she is sufficiently motivated to practice skills taught in therapy. When people experience anxious arousal, they are likely to default to their most well-rehearsed coping strategies. So long as the child has a repertoire of maladaptive behaviors that are functional for avoiding/escaping anxiety-provoking situations (and do not have adverse consequences), there is little reason for him/her to try anything new or challenging.

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Eliminating secondary gain According to the CBT model, a child’s anxious avoidance/escape behavior (or compulsion in the case of OCD) is maintained through negative reinforcement because it removes the child’s anxiety or discomfort. In addition, such behavior may be reinforced by environmental events (secondary gain). For example, when a child who complains of headaches and stomachaches to avoid taking a test at school is allowed to stay home and bake a cake with her grandmother, the child’s behavior is reinforced not only by the relief experienced because she does not have to take the test but also by the opportunity to engage in a preferred activity with the attention of a family member. Attending to the possibility of secondary gain in the family environment is necessary to address barriers to change in exposure-based treatment. Having families keep symptom logs on which they record the antecedents and consequences of anxiety- or OCD-related behavior can be useful for identifying secondary reinforcers that should be removed. If discussing secondary gain brings up attributions of blame, the clinician should remind family members that the child’s anxiety/OCD behaviors are not purposeful even if they seem to have some perks. Secondary gain may be introduced as follows: Often there is more than one reason that a problem is difficult to change. Facing our fears is difficult because it makes us uncomfortable at first. But it could also be difficult because there are perks to having the fears. Sometimes kids get out of doing things they don’t like to do, such as chores or homework, because their fears get in the way. Or, they might get extra time with their parents when they’re afraid. This doesn’t mean that kids choose to have fears, or have fears on purpose, but it does make it harder to get past them. Making sure that there are no perks to having fear/anxiety sets a kid up to be successful at overcoming it.

Validating feelings and prompting coping Parents may need to be taught to validate their anxious child’s feelings. Clinicians should be alert to possible cycles in which a child exhibits heightened distress and a parent, often one who does not suffer from anxiety, appraises the distress as excessive (i.e., not in proportion to the threat). Consequently, the parent dismisses the child’s distress and/or expresses frustration (e.g., “That’s ridiculous, you’re not going to fail the test. You’re an A student”), leaving the child’s feelings invalidated. The child then becomes motivated to convince the parent that the distress is legitimate and selectively attends to confirming evidence that the feared outcome is likely (e.g., “I didn’t have much time to prepare and this teacher is the hardest in the school”). This, of course, leads to increased displays of distress from the child and the cycle continues. It is helpful for clinicians to point out this dynamic when it occurs and

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show parents how they can validate the child’s feelings without validating distorted cognitions that drive them (e.g., “I know this is tough. If I were expecting to fail a test, I’d feel really anxious too.”) Parents can then prompt coping (e.g., “Might it turn out differently? What happened the last time you felt this way?”) PFIT similarly encourages families to respond to a child’s requests for accommodation of symptoms by first asking “Is this your OCD [or whichever language the child prefers] talking?” and validating the emotion (e.g., “I know this is really difficult.”). Parents can then redirect the child to the shared goal of fighting OCD (e.g., “What’s our main goal right now?”) before prompting coping with an open-ended question (e.g., “Is there a skill you can use now?”) Rewarding effort Parents should be taught to reinforce the child’s efforts to cope (“brave behavior”), or his/her small steps, as opposed to just reinforcing successes at completing previously avoided tasks. Praising “process” (efforts and actions) as opposed to “person” (inherent traits; Dweck, 1975) helps youth view their accomplishments as the result of practice, which may enhance their confidence to take on future challenges. Also, specific, labeled praise is preferred (e.g., “I like how you spoke up when the server asked if you needed anything else” as opposed to “Good job”). Families may benefit from the use of a token economy, or a reinforcement system in which “tokens” (e.g., points, coins) are awarded for desirable behavior and can be accumulated and exchanged for “backup reinforcers.” Tokens can be awarded for completing exposure tasks or for taking risks and then traded in for toys, special activities, and privileges. Token economies allow a family to simultaneously targeting multiple behaviors of varying difficulty, though parents are more likely to consistently implement a system that is streamlined (e.g., a few behaviors, simple exchange rates). Many children enjoy earning “brave bucks” that can be saved for larger rewards (Hirshfeld-Becker, 1998). Young children (who lack math skills) may respond to a visual reward system. For example, the therapist of a 4-year old child with selective mutism outlined a cupcake divided into pieces; by vocalizing in various contexts, the child earned colorful “puzzle pieces” to lay over the outline until the image was complete and she was rewarded with a trip to her favorite cupcake shop. Families with a history of conflict might benefit from using the token economy to reinforce child behaviors that are unrelated to anxiety/OCD before tackling symptoms (Peris & Piacentini, 2016). Occasionally, parents are resistant to using rewards because they view them as bribes and/or feel that their child should be

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self-motivated to change his/her behavior. Or, parents may be concerned that providing tangible rewards indefinitely will be expensive. Pointing out that many parental behaviors (e.g., going to work) are sustained with rewards (e.g., a paycheck) can be helpful. Also, the clinician should explain that it will not be necessary for parents to reward brave behavior (e.g., separating from parents) forever; in time, the behavior will become more comfortable for the child and will be reinforced by its natural consequences (e.g., the freedoms that come with being home alone). Rewards/artificial reinforcers are used as a bridge to that point, while the brave behavior is extremely difficult for the child. It is also useful to remind parents that rewards do not have to cost money; children typically respond as well to special time with a caregiver, privileges (e.g., watching television before bed), or decision-making authority (e.g., choosing where the family goes for dinner or what music is played in the car on the way to school). Finally, the clinician can gently point out that the child is not engaging in the desired behavior without a reward, whether or not the parents think he/she should need it; sometimes it pays to let go of the “shoulds” and try something new.

Targeting other familial influences on anxiety Throughout treatment, clinicians can capitalize on opportunities to improve parents’ awareness of cognitive styles and behaviors that they are modeling for their children. Do they verbalize threatening interpretations of neutral situations? Do they catastrophize or expect the worst when confronted with a stressor? Do they avoid stimuli or situations that trigger discomfort (e.g., by using paper towels to touch doorknobs; by declining to answer the phone when nervous about talking to someone)? Does their nonverbal behavior (e.g., facial expressions) reflect alarm when their child is confronted with a challenge? Do they verbalize uncertainty about their child’s ability to cope (e.g., “Are you sure you can do that?”)? Clinicians can help parents get in the habit of asking themselves what message their behavior might send their children. Because children often look to their parents for cues when navigating unfamiliar or challenging situations, parents can minimize a child’s anxiety by modeling calm, neutral responses and expressing confidence in his/her ability. The value of promoting a child’s sense of efficacy for managing anxiety-provoking situations is underscored by evidence that coping efficacy mediates gains in CBT for anxiety, with or without medication (Kendall et al., 2016). Families of anxious children might also benefit from guidance in identifying developmentally appropriate ways to grant autonomy

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(e.g., letting a child resolve peer conflict on his/her own), outside of targeting specific symptoms. Parents can be encouraged to promote their child’s psychological autonomy by allowing him/her to express opinions that are in conflict their own and communicating acceptance of these differences (e.g., Siqueland, Rynn, & Diamond, 2005). Finally, playfully encouraging a child to take risks or leave his/her comfort zone (e.g., through rough-and-tumble play, competition, and performances; “challenging parenting”) might help prevent new anxiety symptoms (Majdandˇzi´c, Mo¨ller, de Vente, Bo¨gels, & van den Boom, 2014; Mo¨ller, Nikoli´c, Majdandˇzi´c, & Bo¨gels, 2016).

Expanding families’ toolkit Behavior management Depending on a youth’s clinical presentation (e.g., the presence of comorbid disruptive behavior disorders) and motivation for treatment as well as the parents’ prior skill set, families might benefit from more focused training in managing behavior to facilitate compliance with therapy tasks. Clinicians can use functional assessment methods to identify antecedents and consequences of behavior (anxiety-related or not), test hypotheses about its functions, and teach families to modify it by applying principles of reinforcement, extinction, and punishment (e.g., Martin & Pear, 2015). It may be useful to borrow from parent training manuals (e.g., Barkley, 2013) to teach procedures such as differential reinforcement and shaping. Communication Drawing from family therapy traditions (Miklowitz, 2008; Sexton & Alexander, 2004), clinicians can use communication skills training to decrease any conflict that interferes with the child’s treatment. After presenting skills for listening and for talking, the clinician invites the family to practice—beginning with a neutral discussion topic and working up to topics likely to elicit intense emotion. The clinician points out any negative patterns; for example, family members interrupting each other, summarizing what others have said inaccurately, or assuming hostile intent that was not expressed (Peris & Piacentini, 2016). Not all families need communication skills training and routinely incorporating it does not appear to improve anxiety outcomes (e.g., Khanna & Kendall, 2009). Session time should be devoted to communication exercises only when they are likely to enhance families’ ability to follow through with exposure.

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Terminating treatment Before terminating successful treatment, clinicians should discuss strategies for preventing a relapse. This involves normalizing setbacks and prompting the child to identify how he/she could respond to “slips” using the skills learned in therapy. Clinicians might also discuss how families can support an “exposure lifestyle” (routinely approaching rather than avoiding anxiety-provoking situations) to prevent new symptoms—especially during times of stress (e.g., transition to a new school). To prevent conflict, have families negotiate who is in charge of any ongoing exposure practice and how parents can check in about symptoms in a way that is developmentally appropriate and comfortable for the child. Clinicians should discuss with parents “red flags” that the child’s OCD/anxiety disorder has returned and that resuming treatment is warranted. Clinicians may also wish to inform parents of early signs of depression, given that it commonly cooccurs with anxiety and adolescence is a high-risk period for its onset (Cummings, Caporino, & Kendall, 2014). Finally, taking time to celebrate the family’s successes will remind youth how far they’ve come with practice and motivate continued improvements.

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C H A P T E R

15 Transdiagnostic exposure-based intervention for anxiety and depression in children and adolescents Michelle Rozenman1, Araceli Gonzalez2 and V. Robin Weersing3 1

University of Denver/UCLA Semel Institute for Neuroscience & Human Behavior, Los Angeles, CA, United States, 2California State University Long Beach, Long Beach, CA, United States, 3Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, CA, United States

Transdiagnostic interventions for internalizing problems What are transdiagnostic interventions? Historically, diagnostic categorizations as identified by the Diagnostic and Statistical Manual (American Psychiatric Association, 2013) have supported the conceptualization of mental health problems as distinct, even when they fit within the same categorization (e.g., social phobia is considered distinct from generalized anxiety, although both fit within the anxiety disorders). Consistent with this categorical categorization, traditional cognitive-behavioral therapy (CBT) manuals focus on individual anxiety disorders as a class, to the exclusion of other psychiatric symptoms or disorders that may also be present. This strategy’s drawbacks include, but are not limited to, the need for the clinician to be well versed in multiple treatment manuals and skills to sequence them,

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the length of time necessary to complete multiple treatments for youth with more than one problem domain, and the requirement for the youth and family to understand each skill learned and when to apply it to address individual symptoms. In contrast, transdiagnostic (or unified) treatments are “those that apply the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses” (McEvoy, Nathan, & Norton, 2009). In a transdiagnostic approach, symptoms of related mental health problems (e.g., anxiety and depression) are conceptualized as sharing the same underlying features, with the expectation that they will respond similarly to the same intervention techniques. Therefore the transdiagnostic perspective focuses on commonalities across, rather than differences between, symptom domains and the client is taught one set of core skills to be broadly applied across them.

Why target internalizing problems as a cluster? Together, anxiety and depression are the most common class of psychiatric problems across development (Axelson & Birmaher, 2001; Costello et al., 2003; Merikangas et al., 2010), and are often collectively referred to as a “near-neighbor” or internalizing “cluster” (Weersing, Rozenman, Maher-Bridge, & Campo, 2012). Internalizing problems cooccur at very high rates (up to 88%; Leyfer, Gallo, Cooper-Vince, & Pincus, 2013; Moffitt et al., 2007; Sørensen, Nissen, Mors, & Thomsen, 2005) and, even in the absence of diagnostic comorbidity, individuals with one diagnosis (e.g., anxiety) also present with either current or history of symptoms from the other diagnosis (Kaufman & Charney, 2000). Youth with anxiety and/or depression also frequently present with somatic complaints (e.g., headaches, stomachaches) and functional pain (Campo, 2012; Campo et al., 2004). The cooccurrence between anxiety, depression, and somatic complaints is not surprising given the theoretical models and empirical evidence for similar processes that underlie each condition. For each condition, theories propose and data support an interplay between several factors, including biological vulnerability to stress (i.e., aberrant neural, psychophysiological, and hypothalamic pituitary adrenal (HPA) axis reactivity; Barlow, Allen, & Choate, 2004; Bird, Mansell, Dickens, & Tai, 2013; Pine, Cohen, Gurley, Brook, & Ma, 1998); hypervigilance/ attention to and anticipation of threat and negativity (Drost et al., 2012; Mathews & MacLeod, 2005); and avoidance and withdrawal in response to feared or anticipated stressful situations (Barlow et al., 2004; Bird et al., 2013; Pine, 2009). Moreover, each condition responds comparably to similar treatments, namely, CBT, behavior therapy (BT), and

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pharmacotherapy with selective serotonin reuptake inhibitors, and symptoms of each condition respond in parallel even when treatment only targets one diagnostic domain (Garber et al., 2016; Garber & Weersing, 2010).

Evidence base for transdiagnostic interventions for internalizing adults A number of studies have examined transdiagnostic CBT for internalizing adults in individual therapy, group therapy, and internet-guided formats (see meta-analyses by Andersen, Toner, Bland, & McMillan, 2016; Garcı´a-Escalera, Chorot, Valiente, Reales, & Sandı´n, 2016; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015; Newby, Twomey, Yuan Li, & Andrews, 2016; Pasarelu, Andersson, Bergman Nordgren, & Dobrean, 2017). Results across these meta-analyses have been quite consistent, finding that transdiagnostic interventions have moderate-tolarge effects on both anxiety and depression symptoms, as well as on quality of life. Transdiagnostic interventions for adult internalizing disorders also outperform control conditions (e.g., wait-list, treatment as usual) and perform comparably to disorder-specific CBT. These results are promising, and suggest that transdiagnostic CBT for adult internalizing disorders may be efficacious.

What do transdiagnostic interventions for internalizing problems look like in youth? While transdiagnostic CBT for adult internalizing disorders in the studies cited previously emphasize cognitive restructuring and behavioral intervention (exposure, behavioral activation) equally, the small but growing extant literature on transdiagnostic interventions for internalizing youth tend to be more focused on emotions and behavior, rather than cognition. In this section, we describe our conceptualization and key treatment target in our work with youth, describe some considerations in applying this approach to youth, and briefly review the evidence base for transdiagnostic exposure-based approaches to internalizing youth.

Conceptualizing avoidance and withdrawal as maladaptive coping responses to stress Avoidance and withdrawal are key clinical impairments in anxiety and depression, respectively. Anxious youth attempt to escape and avoid their feared stimuli and situations, while depressed youth may

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withdraw from activities, people, and situations either because those are triggers for negative emotion and cognition (e.g., “I’m going to stay away from my peers because they make me think about what a loser I am”) or because engagement is too difficult due to low mood, fatigue, or feelings of guilt or worthlessness. While these impairments in anxiety and depression may seem distinct on the surface, they are similar in a very practical way: they are maladaptive coping responses to stress such that the youth no longer does things they want to do (e.g., have fun with friends) or have to do (e.g., go to school) because they feel bad. Critically, both avoidance and withdrawal respond similarly to behavioral approach interventions. We conceptualize graded exposure (in the case of anxiety) and behavioral activation (in the case of depression) as comparable approach behaviors that we call “graded engagement” (Weersing, Gonzalez, Campo, & Lucas, 2008; Weersing et al., 2012). In fact, we nearly always tell our internalizing clients and research participants that the goal of (transdiagnostic) treatment is to “do the things you want to do and have to do” regardless of their clinical picture (anxiety only, depression only, comorbid anxiety, and depression). Conceptualization of avoidance and withdrawal as similar maladaptive coping responses to stress, with the primary treatment target being an increase in approach behavior, is the cornerstone of our transdiagnostic treatment strategy with internalizing youth. We describe implementation of this strategy in greater detail in the second half of this chapter. It should be noted that other transdiagnostic interventions for internalizing youth conceptualized internalizing problems as emotion regulation difficulties (Ehrenreich-May & Bilek, 2012) and avoidance (Chu et al., 2016). A detailed description of other transdiagnostic approaches is outside of the scope of this chapter (for a review, see Gonzalez, 2016). While the conceptualization of internalizing problems as a cluster may influence in which the way the rationale for treatment and skills are presented to youth, all of these approaches are informed by the child anxiety and depression evidence base, and they all focus on increasing functional approach and reducing maladaptive responses (whether they be cognitive, emotional, or behavioral).

What differentiates a transdiagnostic approach from traditional cognitive-behavioral therapy for youth anxiety? Previously we described important distinctions between transdiagnostic and traditional CBT approaches, including conceptualizing problems from multiple diagnostic domains as related, and providing a core set of treatment skills to address both anxiety and depression symptoms. This distinction is especially relevant to the pediatric

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population. First, youth often use language that is nonspecific or does not distinguish between anxiety and mood symptoms (e.g., “I was stressed,” “I felt upset,” “I don’t feel good,” or “my tummy hurts” might be applied to both feared stimuli, sad mood, or other negative emotion). Indeed, the use of umbrella terms to describe symptoms from different diagnostic categories is in line with a transdiagnostic approach. Second and relatedly, youth with symptoms from multiple domains may not be able to articulate or understand which symptoms are more distressing and/or impairing than others, and parents are only able to provide information on what they observe and not necessarily on the child’s internal experience. Addressing symptoms from multiple domains in concert alleviates the burden on the clinician and on the family to only select one symptom domain to address at a time. Although symptom prioritization still occurs within a transdiagnostic framework, symptoms from multiple domains can be targeted simultaneously, as described in detail subsequently. As with any work that may address depressive symptoms, a transdiagnostic framework necessitates consideration of safety issues. And finally, a transdiagnostic framework combines traditional exposure therapy for anxiety with behavioral activation, which can be used to improve mood (or as a reward following difficult exposures), and may also address mood symptoms more broadly. In either case, youth are encouraged to approach situations that are anxiety-provoking, stressful, effortful, boring, or otherwise “hard” that they have been avoiding or from which they have withdrawn.

Advantages of a transdiagnostic approach with children and adolescents As described previously, two primary advantages of a transdiagnostic approach are that the clinician only needs to learn to use one (rather than many) treatment manuals and the youth learn one set of skills to broadly apply across symptoms. This is particularly relevant for younger children and/or those with cognitive or learning difficulties. Next, due to their developmental stage, children in particular may not have the abstract thinking skills to engage in treatment techniques such as cognitive restructuring (Kingery et al., 2006) or know which skills to use in response to specific stressors. Teaching fewer skills in the therapy room to be applied to a broader range of situations and internal experiences (i.e., feeling anxious or low mood) may be more consistent with cognitive and socioemotional development during the pediatric period. In addition, application of one core set of strategies to multiple problem domains, and conceptualization of internalizing problems as

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similar, may increase generalization of treatment skills for both parent and child, and may further serve to prevent onset of future psychopathology. Finally, a transdiagnostic approach may be more cost-efficient and reduce burden on families, clinicians, and systems.

Transdiagnostic brief behavioral therapy for pediatric anxiety and depression Development of brief behavioral therapy In our work, we selected those core skills that appeared to have the strongest evidence base across both adult and child anxiety and depression CBT literatures. What resulted was a fairly behavioral intervention that included psychoeducation, a combination of relaxation and pleasant activities for distress and mood management, problem-solving, and graded engagement, or approach behaviors that include a combination of exposure and graded behavioral activation depending on the individual child or adolescent’s symptom presentation. These treatment components each address underlying vulnerabilities proposed to maintain internalizing problems. Relaxation and pleasant activity scheduling are meant to target biological sensitivity to stress, while problem-solving and graded engagement target maladaptive responses to stress (i.e., avoidance and withdrawal). The bulk of the brief behavioral therapy (BBT) intervention focuses on graded engagement, or behavioral approach. Relaxation, pleasant activities, and problem-solving skills area meant to help youths manage in-the-moment distress, and make decisions to engage in approach behavior. As discussed subsequently, for youth with mixed anxiety-depression symptom presentations, graded engagement includes a combination of exposure and behavioral activation. Of note, the BBT model does not directly address cognitive vulnerabilities with techniques such as cognitive restructuring. We omitted cognitive work in our model in order to (1) bolster the manual’s use with younger (school-aged) children and children with comorbidities such as ADHD, (2) enhance the feasibility of implementation by providers who may not have training or experience with skills such as cognitive restructuring, and (3) pare the intervention down to what we view as the most critical components, based on treatment studies that indicate that behavioral techniques alone cannot produce significant reduction for internalizing symptoms (e.g., Dimidjian et al., 2006; Gould, Buckminster, Pollack, Otto, & Massachusetts, 1997; see Hopko, Lejuez, & Hopko, 2004; Weersing et al., 2008). Thus the omission of cognitive components is an attempt to increase the accessibility and efficiency of the intervention while maintaining effectiveness.

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Brief behavioral therapy evidence base BBT was tested in a large (N 5 185) two-site randomized clinical trial, with very positive results (Weersing et al., 2017). Youth ages 8 17 with primary anxiety, depression, or comorbid anxiety-depression were randomly assigned to receive either BBT in pediatric primary care or assisted referral to care (ARC), which consisted of study staff support to identify community mental health services. Of note, 82% of youth randomized to ARC were connected to services, for a mean of 6.5 outpatient sessions. Nonetheless, 57% of youth receiving BBT, compared to 28% in ARC, demonstrated significant clinical improvement, greater reductions in symptoms, and better functioning. Moreover, ethnicity moderated outcomes, with a significantly greater proportion of Hispanic youth demonstrating response to BBT (77%) compared to ARC (7%). Detailed session-by-session guides for BBT implementation can be found in Weersing et al. (2008) and Weersing et al, (2012). Prior to the publication of our work, a meta-analysis of transdiagnostic CBT for anxiety and depression across children, adolescents, and adults found moderate effect sizes on both anxiety and depression symptoms for children and adolescents (Garcı´a-Escalera et al., 2016). Taken together, these data provide support for the use of transdiagnostic approach-based interventions for internalizing youth. It should also be noted that our randomized controlled trial (RCT) testing BBT (Weersing et al., 2017) was conducted in the primary care setting. Primary care may be a setting in which internalizing youth are especially likely to present for services and are visible to health and mental health providers. Internalizing youth tend to come to the attention of their physicians because primary care is the setting in which these youth present for several reasons: (1) most youth see their primary care provider at least once annually (Costello et al., 1988), (2) many youth present to primary care for services related to their internalizing symptoms (Ramsawh et al., 2012) or somatic or functional pain complaints (Campo, 2012), and (3) parents look to primary care providers for guidance on their children’s behavioral health issues (Horwitz, Leaf, Leventhal, Forsyth, & Speechley, 1992). However, internalizing youth may also present to other outpatient clinical, community, or school health clinic settings for services. Thus while we feel that the BBT intervention is particularly suited to the pediatric primary care setting, and the supporting data were collected in primary care, the intervention can also be applied in other treatment settings. Brief behavioral therapy implementation In the remainder of this chapter, we focus on implementation of BBT with a young adolescent with significant anxiety and concurrent mood

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TABLE 15.1 Brief behavioral therapy (BBT) for youth anxiety and/or depression session summary. Session

Target

BBT treatment elements

1 2

Psychoeducation, treatment rationale, and mood monitoring Biological sensitivity

Relaxation Coping with negative affect Pleasant activity scheduling

3

Maladaptive coping—addressing skills deficits

Problem-solving skills training

4

Maladaptive coping—Reducing avoidance

Reducing avoidance

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

Maladaptive coping—Increasing approach behaviors

Graded engagement

5

6

7

8

9

10

11

Goal setting

Problem-solving

Problem-solving

Problem-solving

Problem-solving

Problem-solving

Problem-solving

Problem-solving Relapse prevention

12

Problem-solving Relapse prevention

and/or somatic symptoms. As described previously, this approach is distinct from traditional CBT for anxiety or depression alone in that it requires the clinician to conceptualize the internalizing symptoms as a problem cluster, which in turn influences the development of

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appropriate graded engagement exercises that may include both traditional exposures to fearful stimuli, as well as behavioral activation activities. The clinician must also either guide the family or work collaboratively to make decisions about several issues, including: (1) prioritizing one symptom domain versus targeting multiple domains with graded engagement, (2) use of problem-solving to facilitate completion of graded engagement exercises in and out of session, (3) regular (each session) safety check-ins for youth with any history of suicidal ideation or significant mood disturbances, and (4) whether and when to address parental psychopathology that begins to interfere with the youth’s treatment (e.g., parent depression interferes with session participation or completion of at-home graded engagement practice). In the below case description and session-by-session summary (see Table 15.1), we provide a practical guide to implementation of BBT in the context of some of the abovementioned issues.

Case example: Emmy Emmy, age 14, presents with symptoms of social anxiety, generalized anxiety, and depression with significant somatic complaints, including frequent headaches and stomachaches. Her mother initiated treatment after noticing that Emmy had become increasingly withdrawn and irritable since starting high school several months prior. Her mother reported that while Emmy used to spend time with friends in middle school, she has been staying in her room a lot more than usual and recently “quit” the basketball team. Her mother described Emmy as “a bit of a worrier,” stating that Emmy worried that might do something to displease her teachers and friends, about events she saw on the news and social media, and about passing her classes. Emmy described feeling “overwhelmed” much of the time. She described social worries; she worried about her friends becoming closer and leaving her out of activities, about speaking in class for fear of saying something incorrectly or ineloquently, and she felt nervous to talk to her teachers, whom she described as “intimidating,” to seek help with school assignments. Emmy also described worrying about “anything and everything that crosses my mind,” including academic achievement, losing friends, getting in a car accident, health of family members, and about what she will do for a living as an adult. She reported daily headaches and stomachaches and that she had been feeling very tired and “blah” for at least 2 months. When her mother was not present, Emmy disclosed to the therapist that she did not quit the basketball team, but that she had been suspended from the team due to a low grade on her most recent school progress report. Emmy reported that she feels like her problems “are too big now, and sometimes I feel like giving up.”

Session 1: Psychoeducation and treatment rationale In the first session with the therapist, Emmy was reserved, quiet, and somewhat guarded. The therapist focused on orienting Emmy and her mother to the BBT model, letting them know that they would focus on specific skills and strategies to help Emmy feel less overwhelmed.

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Emmy’s mother was present for the first part of the session and frequently answered questions on Emmy’s behalf, usually after Emmy provided a curt response. To aid in rapport building, the therapist asked to meet individually with Emmy for the remainder of the session. The therapist made sure to normalize the experience of stress and emphasized that, while everyone experiences stress, sometimes people feel stuck in a heightened state of stress. The therapist explained the concept of “emotional spirals,” emphasizing how events and actions can make our moods spiral both downward and upward. They also discussed the fight-or-flight response to stress and Emmy appeared somewhat relieved as she drew the connection between the body’s stress response and her own somatic symptoms. Emmy remembered learning about the fight-or-flight response briefly in school, but appeared interested when the therapist introduced a new element of the stress response that was unfamiliar to Emmy—the “freeze” response. The therapist linked this response to one’s tendency to withdraw or feel immobilized when feeling overwhelmed. Emmy became more talkative as the session went on and described feeling “triggered all the time” since starting high school. The therapist explained how mood monitoring could help to identify some of those triggers, which they can choose to target during the intervention. When explaining how to complete mood monitoring, the therapist used Emmy’s words to develop a Subjective Units of Distress Scale (SUDS) rating scale that was personalized to Emmy. Emmy described both a heightened anxiety state and a low mood state as feeling “overwhelmed,” so the therapist asked Emmy to rate how “overwhelmed” she felt in various situations, and asked her to consider how strongly she felt an urge to avoid those situations. Emmy appeared anxious as the therapist explained that they would work together to face some of the triggers that overwhelm Emmy and keep her from doing what she wants or needs to do. Emmy’s mother returned to the session for the last 5 minutes, when, with the help of the therapist, Emmy summarized what she had learned about stress and showed her mother the mood monitoring sheet she agreed to complete over the next week.

Session 2: Relaxation and coping with negative affect Critical elements of the BBT structure include setting the session agenda reviewing between-session exercises (may be referred to as therapy “homework,” but the therapist initially shied away from this term given Emmy’s anxiety about her school performance). The therapist praised Emmy for completing mood monitoring on some days and asked her what she learned. Mood monitoring helped Emmy to see

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fluctuations in her mood, helping her realize that maybe she was not as perpetually stuck as she thought. Importantly, her ratings helped her to distinguish when she felt “overwhelmed” due to situations being anxiety-provoking, because they felt “too hard” (i.e., effortful), or because she felt despondent. The exercise also helped Emmy see that her biggest trigger was her low grade, which she blamed for her feelings of discouragement and for keeping her from her friends on the basketball team. She also reported two instances at school that week when she felt hopeless about her school situation and “wished I could just go home, lay in bed, and never get up.” The therapist conducted a safety check, and Emmy denied any intent or plan to harm herself. She and the therapist discussed a plan that Emmy can implement in the event that she has thoughts of hurting herself (which she denied), as well as broader strategies that Emmy can use to help elevate her mood in those moments. This was a natural segue to relaxation skills and pleasant activity scheduling to help reduce immediate distress and regulate emotions. Diaphragmatic breathing, progressive muscle relaxation, and guided imagery exercises were introduced as methods to “relax your body and mind.” Given Emmy’s mood symptoms, the therapist emphasized pleasant activity scheduling as a tool to “relax your world” and described the benefits of planning fun and/or relaxing activities in interrupting negative mood spirals and kick-starting positive mood spirals. In addition to continuing mood monitoring, Emmy agreed to scheduling two pleasant activities, including accompanying her father and dog for a weekend hike and baking cupcakes with her younger brother. Emmy was not particularly enthusiastic about progressive muscle relaxation (“it felt weird”), but felt that breathing and guided imagery may help reduce physical symptoms and disrupt spiraling thoughts. Emmy was a bit skeptical that she would be able to focus on guided imagery, but agreed to try it at least twice before the next session. Emmy’s mother attended the last 10 minutes of the session. Emmy briefly summarized the relaxation tools she had learned. In addition, with the support of the therapist, Emmy disclosed to her mother that she occasionally has passive thoughts of “being gone” when she is feeling very stressed and reviewed the safety plan she had developed with the therapist to help her elevate her mood. Emmy and her mother also discussed ways her mother could support her during those times; Emmy stated that it would be helpful to request hugs from her mother “with no questions asked” and asked her mother to provide Emmy access to the treadmill in her parent’s bedroom in the evening. Her mother agreed to both. They also discussed what to do if Emmy, or anyone else, was in danger of hurting themselves.

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Session 3: Problem-solving skills training The primary agenda item for Session 3 is problem-solving skills training. We guide youth to use problem-solving as a tool to actively address problems over which they have some control (e.g., talking to a friend about something that upset them instead of ignoring them), or to lower physiological arousal and raise positive mood to manage distress in situations over which the youth has little or no control (e.g., visiting a friend down the block when parents are arguing). In BBT, we often use the STEPS framework: S—Say what the problem is (problem definition), T—Think of solutions (brainstorm), E—Examine each one (evaluate potential options by listing pros and cons), P—Pick one and try it out, and S—See if it worked. Emmy realized that her primary goal was getting back on the basketball team. In order to do that, she would need to raise her grade at school which would involve seeking support from her teachers and parents. This seemed extremely daunting to Emmy, as she was nervous about both approaching her teachers and telling her parents the real reason why she was no longer on the basketball team. Emmy defined her problem as “I need to get my grade up to get back on the team, but I don’t know how.” The exercise focused on discussing pros and cons of doing nothing, and the pros and cons of approaching her teacher. Emmy acknowledged that doing nothing would make her more despondent, and that seeking teacher assistance would be beneficial in the long term if it seems difficult now. To help Emmy execute her problem-solving task, she and her therapist developed a broader plan to talk to teachers for assistance with assignments, request an extra credit opportunity, and get advice on how best to study for the class exams. Emmy acknowledged the need for parental support in these efforts and agreed to tell her mother about her grade and sports team status with the support of the therapist in that session. Together, she and the therapist role-played ways to tell mom about the real reason she is no longer playing basketball. Emmy’s mother joined them for the last 10 minutes of the session. Emmy’s mother appeared slightly surprised and worried to hear about Emmy’s low grade, but stated to Emmy that she felt relieved that Emmy and her therapist were developing a plan to talk to the teachers and offered her support in talking to the teachers as well. Emmy told the therapist that the conversation went better than she anticipated it would—she realized that not telling her mother would have provided immediate relief, but would have weighed on her the rest of the week, and that “getting something over with feels good.” Before the following session, Emmy decided to request a private meeting with her teacher and spend some time with her mother brainstorming what she would want to say and ask during the meeting. Although Emmy did not realize it yet, the therapist viewed

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this as an exposure exercise that would be used as a graded engagement example in a later session. Emmy also agreed to practice breathing exercises once daily, guided imagery twice weekly, and complete the two planned pleasant activities.

Session 4: Reducing avoidance and setting goals The first part of the session involved a check-in of the past week, including a safety check, and review of the planned at-home exercises. However, the primary goal of Session 4 is to set the agenda for the remainder of treatment. Emmy and her therapist discussed the role of avoidance in maintaining and exacerbating stress, identifying situations that Emmy avoided, and subsequently selecting major behavioral goals of treatment. The focus on avoidance serves as a rationale for overcoming stress by doing the opposite of avoidance—facing stress in a step by step manner, or graded engagement. Emmy agreed to the conceptualization of her distress and impairment as the result of avoidance of teachers and social events, as well as withdrawal from social interaction, as ineffective strategies to cope with stress and anxiety. The therapist probed for additional avoidance situations, particularly those involving social and generalized worries. Obtaining a range of avoidance situations, along with SUDS ratings of difficulty (Emmy used a scale of 1 10, with 10 being “super overwhelming and hard”) is helpful for planning in-session engagement exercises as well helping to generalize gains of treatment. Emmy disclosed that she had been avoiding calling her friends or commenting on their social media because it made her sad when they posted activities in which she was not included. She wanted to reconnect with them and realized that a major part of her social life revolved around sports. In addition, Emmy wanted to develop closer friendships with other peers from her classes but felt too nervous to initiate contact outside of the class. While Emmy had initially endorsed various generalized worries, Emmy and the therapist agreed to focus on the school- and friend-related social concerns as these were the primary sources of current distress and impairment. To address this, Emmy and the therapist worked collaboratively to generate a list of social tasks that would aid Emmy in reducing her anxiety about reaching out to current friends, fostering new friendships, and approaching her teachers. They then rated each item on Emmy’s 1 10 SUDS scale of how “overwhelming and hard” they seem, and arranged them into a graded list called Emmy’s “Master Plan for Action.” This “Master Plan for Action” appeared similar to traditional exposure hierarchies for social anxiety symptoms, but the focus on increasing social engagement functioned as both exposures for social anxiety and

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behavioral activation for withdrawal and depressive symptoms. Thus both the level of anxiety produced and effort required to engage in each task were considered when ranking each step of the graded engagement list. Finally, Emmy and her therapist discussed how Emmy would rate how “overwhelming and hard” each item was, along with how strongly she felt an urge to avoid the task, and how much relief or pleasure she felt after completing the task.

Sessions 5 10: Increasing engagement and activation The remainder of therapy focuses on progressing through the graded engagement plans (“Master Plan for Action”). These sessions are less didactic and more personalized than previous sections as time is spent enacting the engagement exercises for each youth’s personal plan, practicing skills, problem-solving difficulties that arise, and planning for between-session and future engagement tasks. For Emmy, in-session activities primarily involved practicing communication skills and role playing conversations with teachers related to goal of improving her grade. Notably, these exercises simultaneously functioned as social anxiety exposures. Emmy provided SUDS ratings, as described previously, throughout the exercises. While Emmy reported that some tasks did “get easier,” some continued to “feel hard” to her but she felt more confident in her ability to “survive it” and get through it, even if it still felt overwhelming in the moment. Emmy also engaged in exposures to anxiety-provoking and uncomfortable situations in order to enhance her ability to tolerate discomfort (e.g., asking questions to strangers in the waiting room, reading medical pamphlets aloud to therapist and parent, responding to text message from peers that she had been avoiding). Between-session activities involved a combination of social engagement (e.g., accepting invitations to go to football games with friends, inviting friends to the promenade/shopping center on weekends, asking friends to join for study dates), and executing plans to talk to her teachers privately. Rather than focusing on anxiety reduction, Emmy and her therapist placed a heavy emphasis on functional improvement, and “doing the things you need to do and want to do even if they feel very hard in the moment.” Overall, Emmy did report that tasks became easier, and when they did not, she was able to recognize that she could tolerate the distress and often felt relief and pride after doing something that was difficult. Despite Emmy’s engagement in the earlier sessions, she had difficulty implementing some of the planned between-session engagement exercises following Sessions 5 and 6. For example, after Session 5, Emmy said she “chickened out” before a meeting with her teacher and

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experienced significant stomach upset, and asked her teacher to reschedule due to not feeling well (i.e., avoided meeting with her teacher). During this conversation, Emmy also stated that she “felt like a failure” for both needing the meeting to begin with, and for not being able to follow through with the meeting. She stated that she did not see things getting better. In instances like this, the therapist conducted safety checks and reviewed Emmy’s safety plan. In addition, the therapist found it helpful to use problem-solving as a way for Emmy to see that there were multiple options, and emphasized the last step—try it out and see if it worked—as a strategy to help Emmy feel less stuck and take the opposite action. In addition, the therapist queried about her mood (SUDS) in the moment that she “chickened out” as well as her urge to avoid. The therapist also asked Emmy to recall her mood and urge to avoid the teacher the following day, and now during the session. Emmy noticed that she “felt better right after chickening out,” but that avoiding her teacher did not solve the problem and that now she is feeling overwhelmed and worried about meeting her teacher again. The therapist tied this experience back to the rational for increasing approach and reducing avoidance, and reminded Emmy about her previous successes. The therapist often assessed Emmy’s understanding of this rationale by asking questions such as, “So remind me again, why are we making you do all these hard things?” and, “Tell me again, why is it part of my job to help you feel uncomfortable in social situations?” Questions such as these became a running theme throughout treatment, and despite a few joking eye rolls from Emmy, served as good reminder to her that short-term discomfort can have long-term benefits. Emmy agreed to involve her mother by asking her for her support in talking to her teacher. Specifically, Emmy practiced asking her mother questions that she would ask her teacher, and her mother role-played various responses. They also brainstormed ideas for requests to make of the teacher (e.g., extra credit opportunities, referral to the school’s resource lab, opportunities to receive feedback on drafts of assignments). Following this initial difficulty completing the between-session engagement exercises, Emmy was able to approach her teachers. She reported that the teacher was less “intimidating” individually than she is in class, and that they were able to develop a plan to improve Emmy’s performance in the class. As in several previous exercises, the task went better than anticipated, and was reflected in her current SUDS rating. Emmy reported that she felt relief for the first time in weeks, and this seemed to increase her sense of efficacy and motivation to move up her graded engagement list (“Master Plan for Action”). Alongside these efforts, Emmy became more physically active and socially reengaged with her friends. She denied significant depressive symptoms by Session 8, but continued to feel anxiety in social

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situations. Emmy realized that her social anxiety seemed to drive her avoidance behaviors, and in turn her mood. She agreed to focus on graded engagement exercises targeting her fears of appearing “socially awkward” to others. Emmy’s demeanor appeared noticeably more upbeat by Session 9, and because she was seeing the usefulness of problem-solving and graded engagement exercises, her treatment compliance and engagement also improved. Even though her generalized worries were not targeted in treatment (e.g., worries about what she saw on the news), Emmy reported that her overall improvement in mood helped make those worries more tolerable and less distracting as she focused on more immediate priorities.

Sessions 11 and 12: Review and relapse prevention The final phase of treatment focuses on reviewing progress, consolidating skills, continuing practice, and preventing relapse. Emmy, her mother, and the therapist discussed what Emmy could do if she started feeling “overwhelmed” again with school or friendships. They anticipated upcoming stressors and how Emmy might face them head-on before they presented a big challenge. They reviewed the concept of graded engagement and discussed how Emmy, with the help of her mother if needed, could develop her own “Master Plan for Action” in the future to gradually confront stressful situations. Importantly, they also discussed the value of establishing healthy lifestyle habits, including regular physical and social activities, limiting social media, and maintaining a regular sleep schedule.

General considerations for the implementation of brief behavioral therapy Managing complex symptom presentations Safety assessments and unexpected events It is worth expanding on several themes and general issues that often arise during BBT implementation. First, safety assessments are clinically indicated for treatment-seeking youth, particularly those with mood symptoms. As seen with Emmy, and unlike more cognitive protocols, the safety assessment in BBT does not focus on beliefs or worries about the future. Instead, BBT emphasizes a problem-solving approach to develop a safety plan and elevate her mood. Generally, a problemsolving approach is also helpful to keep treatment on track and goalfocused in cases where the forms of distress, mood triggers, and symptoms may vary week to week—not unusual among youth with

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transdiagnostic presentations. If a therapist is able to help the youth apply the problem-solving framework to the various circumstances, this redirects the session focus from the “problem of the week” to the application of a core skill set. Treatment priorities A second consideration is how best to prioritize treatment goals when youth present with complex symptoms. Emmy entered treatment with a variety of internalizing symptoms, however, treatment focused on targeting the primary areas of distress and impairment, rather than prioritizing a single diagnosis. In essence, it is useful to conceptualize the goals of treatment as helping youth to do the things they need and want to do. In Emmy’s case, avoidance of anxiety and negative affect motivated social withdrawal and feelings of despondence, which were preventing her from reaching her potential in academic and social domains. Graded engagement activities involved a combination of behavioral exposure (anxiety) and activation exercises (depression) as she approached her teachers and reconnected with friends. During treatment, these goals were framed helping Emmy “to do the things you need to do and want to do.” Distress ratings Complex symptom presentations can make mood monitoring slightly tricky if a client cannot focus solely on rating level of anxiety or depression. In BBT, we collect mood ratings throughout treatment, and particularly before, during, and after engagement exercises—the process is the same as collecting SUDS and mood ratings in traditional CBT for anxiety and depression, respectively. However, exactly what is being rated can be slightly less straightforward in transdiagnostic protocols. In BBT, the SUDS ratings are truly subjective units. While some youth clearly describe anxiety or depression as more prominent, some describe general states of “feeling bad.” In Emmy’s case, she identified with the description of “feeling overwhelmed.” Accordingly, the therapist asked her to rate the intensity of her “overwhelmed” feelings, and in doing so, was asked to consider “how hard” various tasks were for her and how strongly she felt an urge to avoid those situations. We recommend that therapists take time in the first session to develop a personalized mood monitoring/SUDS scale to map on to the youth’s description of their distress. This scale will be utilized throughout treatment, at first in daily mood monitoring exercises, and again later when creating and implementing the “Master Plan for Action.”

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Parental involvement Another major consideration is the extent of parental involvement during the treatment process. We appreciate that it can be tricky to find a good balance of parental involvement and youth autonomy. Parents tend to be very involved with younger children and are integral in selecting goals, planning engagement exercise, and reminding youth to complete their practice exercises. By contrast, parents tend to be less involved with teens and, for the older teens, may be present only to receive broad updates and “need-to-know” information. Determining the level of parental involvement with young adolescents, who are transitioning from childhood to adolescence, can be more challenging. Providers need to consider several factors including: (1) maturity of the youth, (2) openness of the parent child relationship, (3) the parent’s desire to know certain details, and (4) the nature of the child’s symptoms. In general, we find it helpful to have an explicit discussion about parent involvement with both youth and parent early in the therapy process (Session 1), and again prior to starting graded engagement exercises (typically around Session 4). From a safety perspective, this includes assuring parents that the youth (perhaps with the help of the therapist) will tell parents anything major that they “need-to-know” (e.g., that they are safe or need their support in keeping safe). In Emmy’s case, her mother was involved in early discussions around safety planning to help ensure Emmy’s safety at home. From a practical standpoint, this involves letting parents know they may be asked for permission from the youth to engage in social activities (e.g., attend school sporting events) or for their help to facilitate engagement activities (e.g., drive them to a friend’s house). It is almost always useful to involve parents in final sessions regarding review of progress, review of skills, and relapse prevention.

Current and future directions for use of trandiagnostic interventions in internalizing youth Despite well-documented similarities between anxiety and depression in terms of shared risk and etiological factors, the literature on the treatment of anxiety and depression has focused on the prevention and treatment targeting anxiety or depression individually, not simultaneously. Evidence to support the transdiagnostic treatment of these two related disorders is burgeoning. A recent meta-analytic review examined intervention trials that targeted either anxiety or depression, but that included measures of the other outcome, to examine the specificity of treatment effects and the extent of cross-over effects on the other

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outcome (Garber et al., 2016). Examination of 27 randomized control trials for the psychosocial treatment of anxiety and depression indicated that treatment effects were strongest for the condition at which the treatment was aimed, yet treatment effects were also significant for the other outcome (i.e., treatments targeting anxiety reduced anxiety and depression, but had stronger effects on anxiety than depression; and vice versa). Thus the data revealed significant cross-over effects—treatment of either disorder has benefits for both problems—and treatments that are not explicitly transdiagnostic by design seem to favorably affect symptoms of near-neighbor disorders. This is exciting, but perhaps not surprising given previous research on shared underpinnings of internalizing problems. Interventions that target the shared mechanisms underlying the development and maintenance of anxiety and depression, as opposed to treating conditions individually, may strengthen the effects of the intervention on both conditions and increase the efficiency of the intervention. The rationale for BBT rests on this foundation. In addition to BBT (Weersing et al, 2017), we are aware of at least two other transdiagnostic treatments for youth in this area, including a youth version of the Unified Protocol for Emotional Disorders (UP; Ehrenreich-May et al., 2017; Farchione et al., 2012; Kennedy, Bilek, & Ehrenreich-May, 2018) and school-based Transdiagnostic Group Behavioral Activation Therapy (GBAT) (Chu et al., 2016). Although these transdiagnostic interventions are similar in targeting anxiety and/ or depression symptoms, the BBT intervention differs from existing models in several ways. As mentioned previously, BBT has a strong focus on behavioral strategies, with a major emphasis on increasing approach and activation behaviors to combat avoidance and withdrawal, which we conceptualize as core maladaptive coping responses underlying anxiety and depression. In addition, BBT spans a broader developmental period (school-age to adolescence) than published transdiagnostic protocols, whose target populations include either school-aged children or adolescents. Lastly, this protocol was embedded in a pediatric primary care setting. However, it is important to note that we do not view this treatment as limited to application in a primary care setting. Although primary care was an excellent setting for BBT, we anticipate that the BBT intervention could just as effectively be implemented in school health clinics, community clinics, and private practice settings. BBT has been evaluated in a face-to-face format, but to increase accessibility of the intervention and aid in dissemination, we envision that BBT may be adapted to other modalities, including web-based video visits with technological supports. In addition, further work is needed to evaluate our hypothesized mechanisms (approach), identify additional mechanisms, and to determine the optimal dose of various treatment components.

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sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives of General Psychiatry, 64(6), 651 660. Available from https://doi.org/10.1001/ archpsyc.64.6.651. Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 49, 91 110. Available from https://doi.org/10.1016/j.cpr.2015.06.002. Newby, J. M., Twomey, C., Yuan Li, S. S., & Andrews, G. (2016). Transdiagnostic computerised cognitive behavioural therapy for depression and anxiety: A systematic review and meta-analysis. Journal of Affective Disorders, 199, 30 41. Available from https://doi. org/10.1016/j.jad.2016.03.018. Pasarelu, C. R., Andersson, G., Bergman Nordgren, L., & Dobrean, A. (2017). Internetdelivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: A systematic review and meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 46(1), 1 28. Available from https://doi.org/ 10.1080/16506073.2016.1231219. Pine, D. S. (2009). Integrating research on development and fear learning: A vision for clinical neuroscience? Depression and Anxiety, 26(9), 775 779. Available from https://doi. org/10.1002/da.20595. Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General Psychiatry, 55(1), 56 64. Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/9435761. Ramsawh, H. J., Chavira, D. A., Kanegaye, J. T., Ancoli-Israel, S., Madati, P. J., & Stein, M. B. (2012). Screening for adolescent anxiety disorders in a pediatric emergency department. Pediatric Emergency Care, 28(10), 1041 1047. Available from https://doi. org/10.1097/PEC.0b013e31826cad6a. Sørensen, M. J., Nissen, J. B., Mors, O., & Thomsen, P. H. (2005). Age and gender differences in depressive symptomatology and comorbidity: An incident sample of psychiatrically admitted children. Journal of Affective Disorders, 84(1), 85 91. Available from https://doi.org/10.1016/j.jad.2004.09.003. Weersing, V. R., Brent, D. A., Rozenman, M. S., Gonzalez, A., Jeffreys, M., Dickerson, J. F., & Iyengar, V. (2017). Brief behavioral therapy for pediatric anxiety and depression in primary care: A randomized clinical trial. JAMAPsychiatry, 74(6), 571 578. Available from https://doi.org/10.1001/jamapsychiatry.2017.0429. Weersing, V. R., Gonzalez, A., Campo, J. V., & Lucas, A. N. (2008). Brief behavioral therapy for pediatric anxiety and depression: Piloting an integrated treatment approach. Cognitive and Behavioral Practice, 15(2), 126 139. Available from https://doi.org/ 10.1016/j.cbpra.2007.10.001. Weersing, V. R., Rozenman, M. S., Maher-Bridge, M., & Campo, J. V. (2012). Anxiety, depression, and somatic distress: Developing a transdiagnostic internalizing toolbox for pediatric practice. Cognitive and Behavioral Practice, 19(1), 68 82. Available from https://doi.org/10.1016/j.cbpra.2011.06.002.

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16 Overcoming challenges in exposure therapy Rachel Canella, Joey Ka-Yee Essoe, Marco Grados and Joseph F. McGuire Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Exposures are a central component of cognitive-behavior therapy (CBT) and form the basis of most evidence-based treatments for youth with anxiety disorders (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016; Peris et al., 2015; Wang et al., 2017) and obsessivecompulsive disorder (OCD) (Lewin, Wu, McGuire, & Storch, 2014). Randomized controlled trials and meta-analyses have found large effects for exposure-based treatments across pediatric anxiety disorders and OCD (McGuire et al., 2015; Wang et al., 2017); see Chapter 3: Psychoeducation for exposure therapy for a detailed review on the efficacy of exposure therapy). This has led experts to recommend exposure-based CBT as the first-line treatment for pediatric anxiety disorders and OCD whether in combination with pharmacotherapy or by itself (Bloch & Storch, 2015; Connolly & Bernstein, 2007). Thus, in almost every case of pediatric anxiety and/or OCD, it is recommended that youth receive exposure-based treatment. Despite considerable empirical support and parental preference compared to pharmacotherapy (Lewin, McGuire, Murphy, & Storch, 2014), several challenges can emerge when implementing exposures in clinical practice. These difficulties may pertain to conducting exposures with child patients, managing parent’s/caregiver’s difficulties implementing exposures outside of therapy sessions, and navigating practical challenges when conducting exposures in therapy sessions. Clinicians with

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experience treating childhood anxiety disorders and OCD were surveyed about possible barriers to implementing exposure therapy in clinical practice. The predominant concerns identified by clinicians related to patient and parent reactions to exposures (e.g., negative parent/ patient responses, treatment dropout, concerns that exposure would make symptoms worse or cause unneeded harm, patient lawsuits; Reid et al., 2017; Stewart et al., 2016). However, there is no empirical support for many of these concerns regarding exposure-based treatment (McGuire, Wu, Choy, & Piacentini, 2018). Unfortunately, clinicians’ concerns about patients’/parents’ reactions to exposure therapy can lead well-intentioned clinicians to employ non-exposure treatment strategies believed to be potentially more benign, but that have less empirical support (e.g., breathing relaxation techniques, progressive muscle relaxation) and may explain (in part) the limited use of exposures in clinical practice for the treatment of child anxiety disorders (Whiteside, Deacon, Benito, & Stewart, 2016; Whiteside et al., 2016). This chapter reviews common challenges with exposure therapy for youth, parents/caregivers, and clinicians. Practical recommendations are offered to navigate and overcome these situations based on clinical experience and expertise. Sample role-plays are used to highlight the implementation of these strategies. In cases in which these challenges persist, the chapter concludes with practical considerations when clinicians should consider pursuing alternative/augmentative treatment approaches and/or a higher level of patient care.

Trouble-shooting exposures with children and adolescents Following an initial evaluation to determine diagnoses and presenting problem, the patient and parent/caregiver should receive psychoeducation about the primary mental health condition and the treatment model of exposure therapy (see Chapter 4: Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy for further detail on psychoeducation for exposure therapy). This allows the patient and parent/caregiver to understand the next steps in the treatment process, and recognize the importance of the exposure hierarchy that will guide treatment. Following psychoeducation, a detailed exposure hierarchy should be developed based on all available information (see Chapter 5: Developing and implementing successful exposurebased interventions for further guidance on developing an exposure hierarchy). After the development of the initial hierarchy, exposures can be designed and implemented (see Chapter 6: Exposure therapy for childhood selective mutism: principles, practices, and procedures for guidance on the development and implementation of exposures).

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Depending on the presenting problem, exposures can be crafted to target selective mutism, separation anxiety, specific phobias, social anxiety, generalized anxiety, and OCD (see Chapters 7 12 for further information on exposures for each condition). Although different theoretical approaches exist toward conducting exposures (habituation vs inhibitory learning, see McGuire & Storch, 2019 for a detailed discussion), there are many similar challenges that arise across theoretical approaches. Two challenges that often arise with youth during exposure therapy include (1) misappraisal of exposure distress and (2) patient resistance to completing exposures. Here, we describe these two challenges in detail and offer practical solutions on how to overcome them.

Misappraisal of exposure distress As noted previously, a detailed exposure hierarchy is an essential feature of exposure therapy. This hierarchy will serve as a road map to help clinicians develop exposures. However, it is not an exact road map. Patients and parents/caregivers are not entirely accurate when anticipating distress and/or difficulty of exposures. For instance, a child with OCD who has contamination symptoms may underestimate the distress evoked by participating in a toilet touching exposure (e.g., initially rated as a 4 out of 10, but in-session is an 8 out of 10). Similarly, parents/caregivers may also misappraise their child’s distress when completing exposures. For example, a parent/caregiver of an adolescent with social anxiety may overestimate the distress that a social exposure elicits (e.g., meeting a new person initially rated as an 8 out of 10, but when encountered in-session is only a 5 out of 10). There are several reasons discrepancies may exist between initial hierarchy ratings and within-exposure distress. In the case of underestimating distress, it may be that situations/exposures on the patient’s hierarchy have never been completed due to family accommodation or ongoing avoidance. Alternatively, in the case of overestimating distress, youth may develop mastery over initial exposures so that later exposures seem less distressing and difficult. Irrespective of the reason for the discrepancy, misappraisal of distress elicited during exposures can be problematic. In the case of overestimating youth distress, the clinician can precede onto a more challenging exposure within the patient’s hierarchy. However, in the case of underestimating distress, the youth may become overwhelmed during the exposure and the clinician may be unsure about how to respond appropriately, or may be unprepared to implement it. Here, we discuss the common occurrence of underestimating the patient’s level of distress from an exposure and offer practical solutions to manage this occurrence.

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Timmy is a 9-year-old boy with OCD who has contamination symptoms. He receives considerable accommodation from his family and regularly engages in avoidance to minimize distress in his daily functioning. Timmy has an intense fear of becoming contaminated from restrooms and only uses the bathroom at home—not at school or in public places. After conducting a thorough evaluation to confirm and rule out other diagnoses, a clinician would provide Timmy and his family with psychoeducation about OCD and exposure therapy. When developing the initial exposure hierarchy, Timmy and his mother might consider “using the boy’s bathroom at school” to be a 10 out of 10—the top of the hierarchy—because it is Timmy’s greatest feared situation. However, Timmy might consider touching the door handle to the school bathroom or touching an item that has been in a public restroom only to be a 5 out of 10 because he would not be in direct contact with the toilet seat or anything he perceives as contaminated. While this seems reasonable at first, there are several concerns with Timmy’s appraisal of anticipated distress. For instance, Timmy has not been inside a “contaminated bathroom” for the past few months. As such, he may not be entirely aware of the amount of distress coming into contact with something that has been “contaminated” may cause him. After completing exposures lower on Timmy’s hierarchy to build his (and his parent’s/caregiver’s) confidence and mastery, a clinician would naturally progress upward on the hierarchy. At this point, the clinician (or Timmy) may select an exposure that involves coming into contact with an item (i.e., a towel) that has been inside a “contaminated bathroom”—a 5 out of 10 on Timmy’s exposure hierarchy. However, as Timmy begins to hold the “contaminated” towel, he becomes increasingly distressed and starts to breakdown in tears because he is now contaminated. While the clinician’s (and parent’s/caregiver’s) immediate instinct may be to provide reassurance to Timmy that he is not contaminated and discontinue the exposure, there are several steps clinicians can take to more effectively manage the situation. Step #1: keep calm and carry on As noted previously, determining a patient’s distress when completing exposures can be complicated by accommodation and avoidance. Thus, it is entirely anticipated that an exposure may elicit more distress than intended due to misappraisal. It is important that the clinician remain calm, and display a neural (yet supportive) reaction to the patient and parent/caregiver. The patient and parent/caregiver will take cues from the clinician on how to respond to the situation at hand, and if the clinician appears to panic, the patient and parent/caregiver may follow suit.

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Step #2: step back but do not stop It is perfectly natural for the clinician to take a step back on the intended exposure. However, it is important that the clinician does not discontinue the exposure entirely. In a supportive manner, the clinician should normalize the patient’s experience and reframe on the situation for the patient and parent/caregiver. For instance, the clinician might say the following: I am really impressed with your effort today Timmy. I understand that this is difficult, and that the exposure we started with today was more challenging that we thought. However, it is completely normal for things to be more difficult that we initially think, especially if we have never tried them before. While we thought that this would only be a 5, it seems like it is a little higher than a 5, maybe an 8 or so. It is really normal to have this happen, and is not anyone’s fault. Even though it is really challenging, I want you to stick with this exposure [touching something contaminated]. However, let’s make some minor adjustments to make a little closer to a 5 instead of an 8. Instead of holding the towel in your hands for the entire session like we planned, let us just see if you can hold on to it for two minutes. . .

By normalizing that patients (and parents/caregivers) sometimes underestimate the distress of exposures, the patient (and parent/caregivers) does not feel to blame or that the patient is not “tough enough” to complete the exposure. Moreover, by providing encouragement and support as the patient (and parent/caregiver) completes a modified version of the initial exposure, the clinician is able to instill confidence in the patient (and parent/caregiver) that the patient can overcome these difficulties. In case the patient is entirely unwilling (or unable) to complete the revised exposure (i.e., Timmy refuses to hold the towel in his hand for even 2 minutes), the clinician may consider pursuing an alternative (yet related) exposure on the hierarchy that still targets the same core fear (i.e., contamination related to the bathroom). When completing this alternative exposure (e.g., touching a bathroom door handle), the clinician should break down the exposure into small steps and monitor the patient’s level of distress at each step to accurately gauge the difficulty of the exposure. Once the desired level of distress is achieved, the clinician should follow the standard exposure procedures outlined above and in prior chapters. By completing an alternative related exposure, not only can the clinician prevent reinforcing avoidance behavior within sessions, but the patient can also experience a sense of achievement and mastery. Moreover, concluding a challenging session on a positive note can contribute to the patient’s motivation to participate in future exposures and homework assignments. However, the clinician should return to the challenging exposure in the near future, so that the patient does not learn to avoid this specific exposure. It can be helpful to use an

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analogy (e.g., sports, video games, playing a music instrument) to help the patient (and parent/caregiver) understand the importance of conquering this exposure and the exposure hierarchy more broadly. For instance, a clinician might say the following if Timmy were unwilling to complete the initial or revised exposure. I completely understand that this is difficult. Let us just try taking a walk down to the bathroom door in the hall. Good, now on that 0-10 scale, what is your level of distress? [Timmy replies a 3.] Great, let us try touching the door handle now, what is your level now that our hands are gripping the door handle. [Timmy replies a 5.] Let us just stay here for a bit and keep our hands on the door handle for a few minutes. . .[After a few minutes]. . .Are you still at a 5 or has it started to go up again? [Timmy replies that it has started to go down to a 4 or a 3.] That is great! Let us keep our hand on the door and see if it continues to go down or up. . .. [While walking back after completing the revised exposure.] Just like when you play baseball on your baseball team, we do not always win the first time we play a new team. Similarly, just because you score more (or less) runs in one inning, does not mean that you will win (or lose) the game. It is more about putting in the hard work to consistently score more runs and outscore the other team in more innings throughout the game. You put in a lot of hard work today, and I am really impressed by your effort. If you are up for it today, I want you to try to do the exposure that we talked about earlier, holding the towel in your hands for two minutes. I really want to give you the chance to score more runs against OCD in this match. . .

This helps the patient understand that they will still have to overcome difficult exposures, but also acknowledges that all exposures do not have to be completed that day or at that exact time. Even when exposures are initially difficult (and the distress underestimated), patients can still overcome them at a later point to “win the match” against OCD. Step #3: processing the experience As the patient calms down and the revised exposure or alternative exposure is completed, the clinician can help the patient and parent/caregiver clarify factors that made the exposure more difficult than anticipated. For instance, did Timmy have a specific worry in his mind associated with holding the towel? Did he experience physiological distress, and if so, what did it feel like for him? Did Timmy react to nonverbal cues from his parent in the room or even the clinician? Did Timmy not entirely understand the scales, and rate most things as a 5 out of 10? This information can help the clinician identify where the difficulty with the exposure occurred, and how to best to modify future exposures. In this instance, Timmy did not have any specific worry associated with holding the towel, but he felt that his hands were becoming sweaty/clammy when he started to hold it. Timmy perceived his

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sweaty/clammy hands to be a sign that his body was reacting to a contaminant on the towel. Thus, any exposure in which Timmy’s hands began to feel sweaty/clammy would indicate to Timmy that his hands were “contaminated.” The clinician could use this information to help Timmy understand that sweaty/clammy hands are sign that his body is nervous (or even excited). As Timmy faces his fears and new situations, it is expected that his hands would be sweaty/clammy because it is normal to be nervous (or even excited) when you are doing things that you have not done before. While this three-step process can help clinicians overcome exposures in which distress is underestimated, there are several strategies that clinicians may employ to help minimize the under-/overestimation of distress in future exposures. Below, three strategies are offered to help clinicians effectively develop exposure hierarchies for youth. First, some patients may have difficulty using the standard 0 10 scale that clinicians use to rank exposures and monitor distress during exposures (i.e., the subjective units of distress scale, SUDS). For instance, a youth might consider everything to be a 10 out of 10, or classify most things as a 5 out of 10. The lack of variability complicates treatment because clinicians may be unsure exactly where to begin exposures or struggle to select exposures later in treatment. If difficulty ranking exposures persists after providing clear anchor point descriptions for SUDS, a clinician may consider using a more simplified or personalized system for ranking exposures. An example of a simplified exposure rating system would be the use of a 3-item scale akin to a traffic light consisting of green, yellow, and red. Green would symbolize an easy exposure, yellow would denote an exposure of medium difficulty, and red would indicate a hard exposure. Indeed, many young children have found this abbreviated color-coded system to be easier to categorize and monitor distress in comparison to a 0 10 scale. Meanwhile, a more personalized system for ranking exposures would be a scale that is tailored to the patient. For instance, a young child who has an interest in animals may use an “animal scale” for ranking exposures and monitoring distress. In this case, the “dog zone” might represent easier exposures, the “cat zone” might represent medium exposures, the “rabbit zone” might represent medium-hard exposures, and the “hamster zone” might represent the exposures that would be hardest for the child. Second, when developing the exposure hierarchy, youth may have difficulty determining whether certain behaviors are “symptoms” or just “preferences/habits.” For instance, Timmy may have stated that he has a “preference” to only use the bathroom at home, and that it is not “OCD.” Meanwhile, Timmy’s parent may believe that Timmy’s “preference” is really a symptom of OCD. In these instances, it is important for a clinician to be objective and not to side with either the patient or

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parent/caregiver. Rather, the clinician should encourage the patient and parent/caregiver to “test it out” and see if changes in this preference result in distress similar to what is experienced when completing an exposure for OCD symptoms. This allows the clinician to incorporate these “preferences” into the patient’s exposure hierarchy, without damaging rapport with either the patient or parent/caregiver. As the patient tests out exposures related to these preferences, the relationship between these “preferences” and “OCD” can be clarified. Finally, when clinicians are collaboratively developing the exposure hierarchy with the patient and parent/caregiver, it can be beneficial to plan ahead and create small steps within each exposure. This serves as a proactive approach to minimize the underestimation of distress. Specifically, the clinician can more precisely monitor the patient’s distress level through each step of the exposure and limit the chance that the patient will become overwhelmed. In the role-play above of the alternative exposure, the clinician had Timmy first walk down the hallway and stand in front of the door and then reassessed Timmy’s level of distress. Then as a separate step, Timmy was asked to grip the bathroom door handle and his distress was reassessed. If the first step had been enough to elicit the targeted level of distress, the clinician could have kept the activity limited only to the first step (and not preceded on to the second step). Meanwhile, if the second step had not elicited an appropriate level of distress, the clinician could consider adding another step to the exposure—turning the door handle but not going into the bathroom. For patients who do not experience noticeable reductions in distress during exposures, it can be helpful to incorporate objective benchmarks into exposures to determine when the exposure is complete. In the above example of the revised exposure, Timmy was asked to hold onto the contaminated towel for two minutes. As Timmy may not experience a noticeable reduction in distress during this short exposure (or have limited insight to accurately report on his distress), the inclusion of objective benchmarks in exposures helps Timmy and the clinician have clear guidelines for the completion of an exposure and monitor therapeutic improvement over the course of treatment (i.e., increasing exposure duration from 2 to 10 minutes). Thus, a detailed hierarchy and exposures that include multiple steps and objective anchors can help clinicians effectively implement exposures without causing the patient to become overwhelmed.

Patient resistance to completing exposures Despite a clinician’s best effort, there may be times that a patient is unwilling to participate in exposures. There may be several reasons for

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such resistance, including that (1) the patient considers the distress of the exposures to be greater than the perceived benefit and (2) the patient does not perceive his/her symptoms to be distressing. It is important to understand the reason behind any resistance to complete exposures as the strategies to overcoming these reasons are different. Short-term exposure distress is perceived to be greater than the long-term benefit Some youth report that the distress elicited by exposures is “too difficult,” or the youth might “not see the point” of exposures due to limited insight into symptoms. When these concerns arise, the clinician may find it useful to implement a developmentally appropriate reward system. Indeed, some research suggests that youth experience a nonlinear reduction in distress that diminishes over the course of treatment (McGuire, Tan, & Piacentini, 2019). Thus, the utilization of a developmentally appropriate reinforcement system can maintain therapeutic momentum when subjective gains begin to diminish in treatment. The clinician should collaborate with the parents/caregivers to develop a reward system to reinforce session attendance, in-session exposures, and completion of homework assignments. This may take the form of a token economy in which youth save up to earn rewards (i.e., small toys, special time with parents, fun activity) or may be exchanged on a daily basis for the reward (i.e., completion of all exposure homework results in an extra 15 minutes of screen time). As items of interest will vary across patients, families, and developmental level, it is important to outline these reinforcement systems early on in treatment to establish a reward program that is motivational and sustainable for both parents/ caregivers and youth. For adolescents who find exposures to be “too difficult” or “do not see the point of them,” it can be useful to inquire about the adolescent’s goals for treatment, personal values, and discern the impact of symptoms on life aspirations. Instead of providing external motivation (i.e., a reinforcement system), this can help the clinician clarify internal motivation to pursue treatment. Discussion surrounding these topics can remind the adolescent about his/her reasons for seeking treatment, and help to maintain the motivation to participate in therapeutic activities. As the adolescent progresses in treatment, the clinician can use this information to highlight the patient’s therapeutic progress, and also draw attention to the hurdles that remain in achieving the adolescent’s life aspirations. Symptoms do not cause distress, so why participate in treatment It is important to understand the patient’s (and parent’s/caregiver’s) motivation to pursue treatment. Are the patient’s symptoms causing difficulties in school or with academic performance? Do the symptoms

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complicate friendships? Do these symptoms impact family functioning? If these symptoms are directly impeding academic and/or social activities, the youngster is likely motivated to overcome these symptoms. However, parents/caregivers may be seeking treatment for the youth’s mental health condition due to significant family dysfunction resulting from ongoing accommodation and avoidance. In the case of Timmy, the 9-year-old with OCD who has contamination symptoms, the family would plan family outings to accommodate Timmy’s avoidance of public restrooms and his reliance on the bathroom at home. While this high level of accommodation and avoidance disrupted many family activities, Timmy did not perceive his avoidance of public bathrooms as problematic because it did not directly disrupt his preferred activities and/or cause him distress due to ongoing accommodation. Thus, Timmy was initially resistant to participate in exposures because his OCD symptoms were not “that much of a problem” from his perspective. The first step is to acknowledge the possible validity of the patient’s belief, namely that these symptoms may not be problematic from the patient’s perspective due to ongoing accommodation and avoidance. A clinician might reframe exposures as “experiments,” “challenges,” and/ or “tests” to see whether activities would bother OCD. This would give the patient (and family) the opportunity to try out these avoided activities and determine the extent to which these activities are problematic without accommodation. This affords the youth some initial independence when “testing out” activities and can help the clinician evaluate the youth’s motivation for treatment. If the patient continues to avoid exposures and/or is resistant to participate in treatment, the second step is to discontinue family accommodation and avoidance. This can be done by having a conversation with patient’s parents/caregivers to develop a plan to limit ongoing accommodation and avoidance. In doing so, it is helpful to first remind parents/caregivers about the function that avoidance and accommodation serve in the maintenance of anxiety and/or OCD symptoms (see Chapter 4: Charting the course of treatment: strategies for developing and optimizing a symptom hierarchy). This will help parents understand the therapeutic role that their efforts will serve in the context of the patient’s treatment. Given that the discontinuation of family accommodation and avoidance may be distressing for the patient and parents/caregivers alike, parents/caregivers may likely require considerable coaching on how to manage the patient’s distress and/or behavioral response (see Chapter 11: Exposure with response prevention for obsessive-compulsive disorder in children and adolescents for further discussion of involving family members in exposure therapy). A gradual approach is often the easiest way to start the discontinuation of family accommodation and avoidance—as these behavioral patterns

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have been engrained into the family routine. As accommodation and avoidance are discontinued, the patient will receive the opportunity to confront exposures within a naturalistic setting. In many cases, the patient will begin to recognize that these symptoms are problematic, which eventually will lead to participation in treatment and withinsession exposures. However, in case the patient is still resistant and/or entirely unwilling to participate in treatment, there is some evidence that parent-only treatments can be useful to treat anxiety disorders and OCD in children and adolescents (Lebowitz, 2013; Lebowitz, Omer, Hermes, & Scahill, 2014).

Trouble-shooting exposures with parents and caregivers As described previously and in previous chapters, parents and caregivers play an important role in exposure therapy. Specifically, they can model exposures outside of therapy sessions, maintain adherence with exposure homework, and reduce family accommodation and avoidance. Given that parents/caregivers play a key role in exposure therapy for many youth, it is important to promptly address challenges that may arise with parents/caregivers so that treatment can progress effectively and efficiently. Two common challenges for parents/caregivers participating in exposure therapy relate to (1) difficulty understanding the underlying principles of exposure therapy and (2) difficulty implementing exposures outside of therapy sessions.

Difficulty understanding underlying principles of exposure therapy Although a clinician may provide initial psychoeducation about the patient’s mental health condition(s) and the exposure therapy treatment model, parents/caregivers may not fully understand the nuanced aspects of treatment. For instance, parents/caregivers may not initially understand the connection between exposures and therapeutic improvement, and perceive exposures as causing more harm than good. Alternatively, parents/caregivers may have difficulty recognizing the presence of family accommodation, avoidance, and/or reassurance that they provide to the patient. Indeed, these behaviors may go unnoticed (or unspoken about) by parents/caregivers for considerable periods of time. Thus, after providing psychoeducation, it is helpful for clinicians to check-in on the patient’s and parent’s/caregiver’s understanding of the treatment model. This provides clinicians with the opportunity to

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evaluate understanding and provide corrective feedback on the treatment model. For instance, a clinician might say the following: I know that I have been talking a little bit about this approach to treatment, and I know sometimes I can be a bit confusing. I want you to tell me in your own words what I have said about this approach to treatment, just to make sure that I have done a good job of explaining things. . ..

[If the patient and/or parent has difficulty articulating the appropriate approach to treatment, the clinician might respond with the following. . .] . . .You did a real nice job of putting it into your own words! It was really close to what I said, but I think I might have missed some points when I was explaining it earlier. Let me go over it again to make sure that I covered everything, and then I’ll ask you to repeat it back to me, but again using your own words.

This allows the clinician to diffuse any blame regarding the misunderstanding of the treatment model, and allows the clinician to make sure the patient and parent/caregiver accurately understand the approach to treatment. If the parent/caregiver understands some aspects of treatment but does not fully comprehend all aspects, then the clinician should tailor the revised explanation to address the specific knowledge gaps. For instance, in case the parent/caregiver understands that patient will participate in exposures but does not understand that family accommodation and avoidance will have to be discontinued as well, a clinician might say the following: You did a real nice job of explaining things in your own words! I really liked how you noted that Timmy would have to complete exposures to get over his fears and worries, and how over time things will get easier for Timmy with practice. I just wanted to follow-up on one related part that I might have missed when I was explaining things earlier. Accommodations related to OCD symptoms and avoidance of situations that trigger OCD distress will also be targeted in treatment. Examples of accommodations related to OCD include modifying family activities so that Timmy can go home to use the bathroom. Similarly, an example of avoidance might be planning daily activities so that Timmy does not have to come into contact with public restrooms. So, over the course of treatment, while Timmy will be facing his fears and worries though exposures, I will be asking you and your family members to increase Timmy’s opportunities to practice his exposures by discontinuing accommodations and avoidance behaviors in a gradual manner. We will work these accommodation and avoidance behaviors into Timmy’s exposure hierarchy.

This approach praises the parent/caregiver for understanding aspects of the treatment model, and addresses knowledge gaps related to accommodation/avoidance in a supportive manner. In case the parent/ caregiver has ongoing difficulty articulating the treatment model and/ or understanding the approach to treatment, it can be helpful to use an

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analogy to help the patient and parent conceptualize treatment in a relatable manner. For instance, if the patient plays sports, the clinician could use a sports analogy to portray the treatment approach and clarify treatment roles. In a sports analogy, the clinician can be thought of as the “coach,” the patient as the “player,” the parents/caregivers as the “cheerleaders” or “referees” (depending on how the clinician wishes to incorporate the parents/caregivers), the therapy sessions as “practice” and outside homework activities as “games.” By using an analogy, parents/caregivers can understand the importance of exposures and therapy sessions in a relatable manner, as well as their role in the patient’s treatment.

Difficulty implementing exposures outside of therapy sessions While addressing knowledge gaps in the treatment model is important, parents/caregivers may struggle to implement exposures and related activities outside of treatment. For instance, parents/caregivers may have difficulty discontinuing family accommodations and/or avoidance behaviors that have become routine in family life. Additionally, parents/caregivers may have difficulty ensuring the patient’s exposure homework is complete due to their own unwillingness to complete some exposures (or monitor them). Finally, some parents/caregivers may have difficulty with exposures outside of treatment sessions, and push the patient either too little or too much during these activities. Here, we discuss common difficulties when parents/caregivers are asked to implement exposures outside of therapy sessions. Persistent accommodation Parents/caregivers and other family members often provide accommodations to the patient to minimize anxiety and/or OCD-related distress. The intention of the family member is to provide support for their loved one, and they often perceive the accommodating behavior as serving this function. Although limiting distress in the short term, accommodation ultimately serves to sustain anxiety and/or OCD symptoms in the long-term. When family accommodation persists over the course of treatment, clinicians should inquire about the parents’/caregivers’/ family members’ reasons for continuing to provide accommodation in order to effectively address it. These reasons may include (1) a belief that accommodation minimizes patient distress and/or family conflict or (2) limited experience implementing alternative responses instead of accommodating the patient. Family accommodation may persist because parents/caregivers believe accommodations will help the patient experience less distress,

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complete daily activities, and/or minimize family conflict. For instance, a parent/caregiver may continue reading the patient’s homework to him/her each night to limit the patient’s rereading and rewriting symptoms of OCD—allowing the patient to complete his/her homework in a timely manner and avoid conflict surrounding academic performance. When ongoing accommodation is identified, it is useful to inquire about the parent’s/caregiver’s awareness of the ongoing accommodation and incorporate discontinuing such behavior into the patient’s exposure hierarchy. If the parent/caregiver is resistant to removing accommodation, clinicians should supportively remind the parent/caregiver about the role of accommodation in treatment and inquire about any barriers to removing this accommodation. As barriers are identified, the parent/ caregiver and clinician can engage in collaborative problem solving to overcome these barriers. Using the example above, the clinician could write a school letter to request a reduced amount of homework for the patient as the patient practices exposures for the rereading/rewriting symptoms. This would overcome the need for parent involvement in homework completion, and as the patient gains mastery over the rereading and rewriting symptoms, the amount of homework could return to the normal level. When discontinuing accommodation, parents/caregivers sometimes struggle to implement alternative responses instead of providing accommodation. This is a common difficulty because accommodating behaviors have been engrained into family life. Indeed, it can be particularly difficult if the patient exhibits disruptive and/or coercive behaviors to obtain accommodation from family members (i.e., crying or yelling when accommodation is not provided). A clinician can validate parents’/caregivers’ feelings that changing behavioral patterns is difficult, and acknowledge that it takes time and practice to make lasting changes. Afterward, the clinician can help parents/caregivers plan and implement alternative responses to accommodation. In the case described previously in which the parent was reading the patients’ homework aloud each evening, the parent might be instructed to give the child a reminder prompt to do his/her homework and then leave the room. If the patient continues to seek accommodation, the parent might be coached to say something like, “I know that it can be really hard to fight OCD, and I am impressed by your effort. I want to help you and support you as much as possible. However, if I read your homework, it will really help OCD and not you. Like we talked about in the therapy session this week, I am going to step out of the room and give you the opportunity to practice your exposures.” As the patient may struggle with the removal of accommodation, some disruptive and/or oppositional behaviors can emerge. In these cases, parent training strategies can be useful to manage such behaviors (Sukhodolsky, Gorman, Scahill, Findley, & McGuire, 2013).

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Unwillingness to monitor and/or perform exposures outside of therapy visits Homework compliance is an integral part of exposure therapy for anxiety disorders and OCD. Accordingly, parents/caregivers play an important role in helping youth complete exposures outside of therapy sessions. However, sometimes parents/caregivers may be unwilling to watch (or participate in) an exposure themselves. This can be problematic because parents/caregivers may respond to an exposure with negative affect, or that their refusal to be involved in an exposure may suggest to the patient that there is something negative about the exposure and/or its consequences. Early in treatment, clinicians should remind parents/caregivers about their role in homework assignments and discuss exposures on the patient’s hierarchy that may be difficult for the parent/caregiver—without the patient present. This can help clinicians develop exposure exercises that can be appropriately implemented outside of the session with parent/caregiver support, and remind parents/caregivers to monitor their own emotional reactions during exposures. However, there may be some exposures on the patient’s hierarchy that are too difficult for parents/caregivers to complete. When this occurs, the clinician should collaborate with the parent/caregiver to identify a support person that could function as a “stand-in” during these particular exposures (e.g., the other parent/ caregiver, grandparent, sibling, cousin). Pushing too little or too much during exposure homework Practicing exposures outside of therapy visits is important. However, not all practice is equivalent to in-session exposures conducted under the supervision of the clinician. Thus, it is important to review the implementation of exposure homework early-on in treatment to ascertain whether exposures are being conducted appropriately by patients and parents/caregivers. When reviewing exposure homework, parents/caregivers may report difficulty with implementing exposures due to patient distress elicited by exposures and/or concern about the consequences to the patient. For instance, a parent/ caregiver may permit a patient to engage in washing ritual after completing contamination exposures (i.e., touching the toilet and then washing hands). Alternatively, parents/caregivers may be too ambitious—removing accommodation too quickly or setting unrealistic expectations for the patient’s exposure performance. Using the same above example, a parent might expect the patient to refrain from washing his/her hands the entire day, or remove all hand soap from the bathroom to prevent ritualized hand washing following exposures.

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When parents/caregivers are pushing too little or too much during exposure homework, clinicians should encourage parents/caregivers to practice exposures that are consistent with those observed in therapy sessions. If the parent is not adhering to the exposure procedures outlined in therapy and is allowing the patient to ritualize/avoid, a clinician might say: I really appreciate how you have been working with Timmy on his exposure homework. When Timmy and you have been describing the exposures at home, I noticed that you allow Timmy to wash his hands immediately following the exposure. While that might make sense in most situations, for the purposes of the exposure and Timmy’s treatment, it would be best if Timmy did not wash his hands until his hands are visibly dirty (or right before dinnertime). That is, the step that we are working on in Timmy’s exposure hierarchy. This way we are keeping Timmy’s hand washing behaviors consistent with other members in the household and supporting Timmy as he fights OCD.

It is important not to assign blame to the patient, parent/caregiver, or clinician for this misstep. Rather, the clinician should provide corrective feedback so that exposures at home are implemented appropriately. If discontinuing accommodation is difficult or parents/caregivers are worried about disruptive behaviors, the strategies in the above section can be applied. Meanwhile, if parents/caregivers are expecting too much during exposures, a clinician might say: I really appreciate how you have been working with Timmy on his exposure homework. When Timmy and you have been describing the exposures at home, I noticed that you have removed all of the hand soap from the bathrooms. While I am impressed that you realized that access to the hand soap might be an accommodation, we are not at the point in Timmy’s exposure hierarchy where it should be removed. I’m grateful that you think Timmy has progressed so much that he can manage that challenge, but I also want to make sure we set Timmy up for success in beating OCD. So for the time being, let’s plan to leave the hand soap in the bathroom for the next week, and then based on Timmy’s treatment progress, we can see if he’s ready for its removal next week.

If the parent/caregiver is having difficulty understanding why expectations cannot be set higher or accommodation cannot be immediately removed, an analogy can often be helpful to exemplify the situation. Using the previous baseball analogy, the clinician might describe setting an expectation too high or removing accommodation too quickly as having Timmy face difficult opponents in his baseball league. While the Timmy might “score a few runs” initially, he might also get overwhelmed because the opponent is “too difficult” and stop trying all-together because he “can’t win the game.” It would be better to have Timmy start playing opponents at his level to help him develop mastery and confidence before he starts to face more challenging opponents. This way,

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Timmy is setup for success and faces more challenging exposures with greater confidence.

Trouble-shooting exposures with clinicians As noted previously, clinicians with experience treating childhood anxiety disorders and OCD were surveyed about barriers to using exposure therapy in clinical practice. The predominant concerns identified by clinicians related to negative patient and parent/caregivers reactions to exposures (Reid et al., 2017; Stewart et al., 2016). However, when comparing exposure-based CBT to psychoeducation with relaxation training (PRT) in a randomized clinical trial of pediatric OCD, there was no difference between groups for participant dropout or therapeutic relationship between youth and therapists (McGuire et al., 2018). Interestingly, youth who received exposure-based CBT had greater parental satisfaction compared to youth who receive PRT, with a moderate relationship found between treatment satisfaction and symptom severity reductions (McGuire et al., 2018). Thus, well-intention clinicians should be assuaged that there is no empirical support that exposure therapy will result in negative reactions from patients and parents/caregivers to a greater extent than non-exposure treatments. However, clinicians may face several practical challenges when conducting exposure therapy for childhood anxiety disorders and OCD. These challenges can pertain to (1) access to resources needed to conduct exposures and (2) access to education/training/experience to conduct exposures. Here, we present solutions to navigate and overcome these challenges.

Access to resources to conduct exposures Clinicians may feel as though they do not have the items needed to conduct exposure therapy in the office. Given the broad array of anxiety symptoms and the heterogeneity of OCD symptoms, it can be challenging for a “first-time” clinician to possess the diverse array of items that may be needed for exposures. First and foremost, it is important for clinicians to plan ahead for what items may be needed for a patient’s exposures. A detailed exposure hierarchy developed at the start of treatment will help a clinician identify items that are necessary for exposures and prepare appropriately for later therapy sessions. For instance, if a patient has emetophobia (fear of vomiting) and acrophobia (fear of spiders), the clinician should be prepared to acquire fake vomit (there is a surprisingly large array of recipes on the internet) and fake (or real)

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spiders for future exposures. Over time, as clinicians continue to treat youth with anxiety disorders and/or OCD, clinicians often amass a “tool kit” that contains the common items used for exposures. However, clinicians can also be creative with items found in the office for exposures. For instance, items in the trash bin might be used for a contamination exposure or diplomas/certificates hanging on the wall could be arranged for symmetry exposures. Second, while some exposures can be completed within a clinician’s office (i.e., sorting contaminated items in the office trash bin), it may prove challenging to coordinate some exposures due to limited availability of resources. For instance, an adolescent with acrophobia (fear of heights) and/or glossophobia (public speaking) may be able to practice small exposures within or nearby a clinician’s office (i.e., climbing stairs with the clinician and looking over the edge, giving a speech to three confederates in the clinician’s office). However, these exposures can take considerable time on the clinician’s part to setup (i.e., getting three staff together for the exposure at the same time) and the resources may not always be available during the patient’s exposure sessions. Additionally, clinicians may not have access to resources that are needed for particular exposures due to limitations in the office (i.e., no access to stairs or elevated heights for acrophobia exposures). Although the clinician might assign these exposures for homework, it is helpful to conduct some of these exposures in session to give patients (and parents/caregivers) the confidence to try them outside of session and troubleshoot any challenges that may arise. When some exposures seem inaccessible due to resource /setting limitations, immersive virtual reality (VR) represents one possible solution to assist clinicians. Immersive VR headsets are increasingly affordable and the accompanying VR exposure software are becoming more realistic. There is considerable empirical support for using immersive VR exposures for many anxiety-related disorders in adults (Carl et al., 2019) and growing evidence that it is efficacious for youth with anxietyrelated disorders as well (St-Jacques, Bouchard, & Be´langer, 2010). Indeed, clinical trials in adults with social anxiety disorder have found that in vivo exposures and in virtruo exposures produced comparable therapeutic benefit (Bouchard et al., 2017). Thus, immersive VR provides patients the opportunity to complete exposures within seemingly naturalistic and hard-to-encounter environments (i.e., heights, speaking in a large auditorium or classroom) within the comfort of a clinician’s office. Moreover, clinicians (and patients) have considerable control over these exposures, which allows the exposure to be conducted with careful precision. Finally, there may be times in treatment when a clinician is entirely unable to conduct in vivo (or in virtuo) exposures for specific fears or

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worries. This often occurs because the patient’s fear or worry involves a future event that will not happen for some time (i.e., death, dying). For instance, a child with OCD may be concerned that a contamination exposure will result in his parents being severely harmed and/or dying due to contamination. Completing this in vivo exposure would prove impossible within (or outside) of a therapy session. Instead, a clinician can consider using imaginal exposures instead of in vivo exposures. While in vivo exposures are characterized by directly facing the distressing situation or stimulus, imaginal exposures use vivid imagery (often times in a script, narrative, or recording) to expose the patient to distressing situations and stimuli. An imaginal exposure still targets the patient’s core fear associated with contamination symptoms (i.e., harm coming to his parents from completing exposures), and allows the patient to experience the feelings and distress associated with this imagined experience. Although less preferred than to in vivo exposures, imaginal exposures can help complete challenging exposures and can be done within a clinician’s office. Using the above example of the child with OCD, the clinician could collaborate with the patient to develop an imagined story about a time that the patient completed a contamination exposure and the patient’s parents had a negative outcome. The imaginal exposure might start off basic and with little detail (i.e., “I did not wash my hands and touched my parents and they got sick”). However, over successive trials, the imaginal exposure should become more detailed and the negative outcome increased in its deleterious effect (i.e., “Yesterday, I got home from school after touching many dirty books and door handles. I could feel the germs all over my hands. However, my parents asked me to help set the table before dinner. As part of my exposure homework, I didn’t wash my hands before helping to set the table. At dinner time, I noticed that both my parents licked the plates that I had touched with my dirty unwashed hands. I expected them to immediately get sick, but nothing bad happened that night. However, I noticed over the next few days that my parents started to get sick. Each passing day they became sicker and sicker. Soon we had to take them to the hospital where they died.”). This imaginal exposure could become assigned reading for the patient as part of his homework assignment. Access to education/training/experience to conduct exposures The practice of exposure-based treatments can be difficult, even for a seasoned clinician who has experience treating childhood anxiety and OCD. Educational materials (like this book) serve as resources to help educate and prepare clinicians to apply exposure therapy within their practice. However, some patients and exposures can prove challenging for a variety of reasons as noted above. After obtaining and reading educational materials, some clinicians can achieve competency to

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practice exposure therapy. However, many other clinicians may be interested to receive further education and training on using exposure therapy. There are several options. For instance, many academic and organization-specific conferences offer “Master Clinician” seminars in which attendees receive training from an exposure therapy expert who provides information on implementing exposure therapy within a specific patient population. These seminars often involve sample role plays or case illustrations to exemplify how therapeutic techniques are implemented in practice. The Association of Behavioral and Cognitive Therapies (ABCT) offers several “Master Clinician” workshops on an annual basis. Similarly, the International OCD Foundation (IOCDF) offers Behavior Therapy Training Institutes (BTTI), which consists of a 3-day training workshop for treating OCD and related disorders using exposure-based treatments. Although these are just two examples of the many “hands-on” educational workshops available to clinicians, they highlight the availabilities and opportunities for clinicians to receive further postgraduate training on exposure therapy.

Conclusion Although exposure-based treatments are efficacious for anxiety disorders and OCD in children and adolescents, exposures can be challenging to implement in clinical practice. This chapter reviewed common challenges with exposure therapy for youth, parents/caregivers, and clinicians. Practical recommendations were offered to overcome difficulties implementing exposure therapy based on clinical experience and expertise. When implemented appropriately, these recommendations will help clinicians overcome these common challenges and help patients and their families achieve therapeutic improvement. Despite a clinicians’ best effort to provide evidence-based care, there may be some patients who do not initially (or adequately) respond to exposure therapy. When patients do not improve in treatment, the aforementioned challenges should be closely examined and solutions implemented as needed. In case youth remain unresponsive, clinicians should consider the three following options. First, it is important to consider whether the patient requires pharmacotherapy along with exposure therapy. Indeed, clinical trials have found positive treatment outcomes for youth who receive the combination of exposure-based treatments and evidence-based pharmacotherapy (Pediatric OCD Treatment Study (POTS), 2004; Walkup et al., 2008). However, if the patient is already receiving pharmacotherapy, a second opinion may be useful to determine whether the current medication regimen is optimal. Second, if parents/caregivers are not open to pharmacotherapy or the

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patient’s symptoms are not severe enough to warrant pharmacological intervention, the clinician may consider integrating acceptance and commitment therapeutic techniques into treatment (see chapter on enhancing exposures using acceptance and commitment therapy (ACT) principles). This approach to treatment can help patients use both exposures and therapeutic techniques like acceptance and mindfulness to overcome anxiety- and OCD-related distress. Finally, if the patient remains unresponsive to these two approaches (i.e., augmenting with medication or ACT), it is important to consider whether a higher level or more intensive treatment approach is need to effectively manage the patient’s clinical presentation.

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McGuire, J. F., Tan, P. Z., & Piacentini, J. (2019). Symptom dimension response in children and adolescents with obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 48(3), 529 538. McGuire, J. F., Wu, M. S., Choy, C., & Piacentini, J. (2018). Editorial perspective: Exposures in cognitive behavior therapy for pediatric obsessive-compulsive disorder: Addressing common clinician concerns. Journal of Child Psychology and Psychiatry, 59(6), 714 716. Peris, T. S., Compton, S. N., Kendall, P. C., Birmaher, B., Sherrill, J., March, J., . . . McCracken, J. T. (2015). Trajectories of change in youth anxiety during cognitivebehavior therapy. Journal of Consulting and Clinical Psychology, 83(2), 239. POTS. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292(16), 1969 1976. Reid, A. M., Bolshakova, M. I., Guzick, A. G., Fernandez, A. G., Striley, C. W., Geffken, G. R., & McNamara, J. P. (2017). Common barriers to the dissemination of exposure therapy for youth with anxiety disorders. Community Mental Health Journal, 53(4), 432 437. St-Jacques, J., Bouchard, S., & Be´langer, C. (2010). Is virtual reality effective to motivate and raise interest in phobic children toward therapy? A clinical trial study of in vivo with in virtuo versus in vivo only treatment exposure. The Journal of Clinical Psychiatry, 71(7), 924 931. Stewart, E., Frank, H., Benito, K., Wellen, B., Herren, J., Skriner, L. C., & Whiteside, S. P. (2016). Exposure therapy practices and mechanism endorsement: A survey of specialty clinicians. Professional Psychology: Research and Practice, 47(4), 303. Sukhodolsky, D. G., Gorman, B. S., Scahill, L., Findley, D., & McGuire, J. (2013). Exposure and response prevention with or without parent management training for children with obsessive-compulsive disorder complicated by disruptive behavior: A multiplebaseline across-responses design study. Journal of Anxiety Disorders, 27(3), 298 305. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., . . . Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359(26), 2753 2766. Wang, Z., Whiteside, S. P., Sim, L., Farah, W., Morrow, A. S., Alsawas, M., . . . Beuschel, B. (2017). Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatrics, 171(11), 1049 1056. Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29 36. Whiteside, S. P., Sattler, A., Ale, C. M., Young, B., Hillson Jensen, A., Gregg, M. S., & Geske, J. R. (2016). The use of exposure therapy for child anxiety disorders in a medical center. Professional Psychology: Research and Practice, 47(3), 206.

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17 Acceptance and commitment therapy enhanced exposures for children and adolescents Anna E. Allmann1, Lisa W. Coyne2, Rebecca Michel2 and Robert McGowan3 1

Columbia University Clinic for Anxiety and Related Disorders, Columbia University, Tarrytown, NY, United States, 2McLean OCD Institute for Children and Adolescents, Harvard Medical School, Middleborough, MA, United States, 3The University of Scranton, Scranton, PA, United States

I can’t do that exposure, it’s too hard. I don’t think this exposure task is making me anxious enough. Because this exposure is happening in treatment and not in my real life it won’t work. You’re asking me to do the scariest thing I can imagine doing; it feels impossible!

As an exposure and response prevention (ERP) therapist, these are just a few of the apprehensions you may hear while working with children and adolescents with anxiety disorders. As you will discover, acceptance and commitment therapy (ACT) may be an effective adjunctive tool to address some of the common responses to the first-line treatment for anxiety disorders, ERP. As a clinician, you are likely very aware of the staggering rates of anxiety disorders and symptoms in youth. A meta-analysis found the worldwide prevalence of any anxiety disorder in childhood and adolescence was estimated at 6.5% (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015). Additionally, given the high 3-month prevalence rates of anxiety disorders in youth (Costello, Mustillo, Erkanli, Keeler, &

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Angold, 2003; Merikangas et al., 2010) it is one of the most likely presentations to walk into your office. Generally, we understand anxiety disorders as based in avoidance behaviors. In order to avoid anxiety or discomfort, individuals may refuse to attend school, avoid their homework, remove themselves from friendships or social gatherings, or fail to engage in healthy interpersonal relationships. At severe levels, adolescents may become trapped in one room of their house, or even one spot on a couch, for hours, days, or weeks at a time in an effort to avoid any possible contact with their anxiety. These avoidance behaviors have manifold implications for emergent adolescents and can derail youth from appropriate developmental trajectories. Parents and siblings are also often participants, albeit unwillingly, in the child’s efforts to manage or avoid anxiety. In the family context, parents can become enmeshed in coercive patterns with their children that include bribery or threats, or alternately, parents can take on the role of emotion regulation and accommodation of anxious behaviors for their children. Each of these patterns can exacerbate the intensity and duration of an adolescent’s avoidant coping (Wood, McLeod, Sigman, Hwang, & Chu, 2003). ERP treatment seeks to reduce avoidance behaviors and to increase effective distress tolerance, thereby allowing youth to resume participating in their lives and meeting developmental milestones. Unsurprisingly, asking a young person to engage in a situation that is perceived as tremendously scary or dangerous and that was previously avoided is often difficult both for the child and for the child’s family members to accept or be willing to try. While the work of ERP may feel intolerable for some, significant research exists supporting its use to treat anxiety disorders, particularly in adults (Deacon & Abramowitz, 2004; NICE, 2006). Although fewer studies exist evaluating the efficacy of ERP to treat children and adolescents with anxiety disorders, some studies do establish that the effects in adults also generalize to youth (Higa-McMillan, Francis, RithNajarian, & Chorpita, 2016), and it remains the treatment of choice for many practitioners using evidence-based techniques. Despite ERP’s reputation as a gold standard of treatment, as with any treatment modality, some common challenges may arise in practice ranging from treatment refusal to the use of distraction, with significant variability from person to person. Even when implemented properly, some individuals are deemed treatment nonresponders or are unwilling to experience and tolerate the intense anxiety that ERP may elicit. Complementary third-wave cognitive-behavioral approaches such as ACT when employed in combination with ERP treatment may increase treatment willingness, flexibility, adherence, and overall symptom reduction. In this chapter, we describe how ACT can be integrated with ERP to optimize outcomes. We begin by briefly discussing current best

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practices for utilizing ERP. We then provide an introduction to ACT, review the evidence for integrating ACT into ERP, discuss the importance of effectively integrating the family into the work, and offer specific examples and sample treatment plans with corresponding exposure tasks that are both ACT and ERP consistent. We frame all of this discussion from the perspective that ERP is on its own an effective, often transformative tool; however, ACT may enhance its effects, shape willingness and flexibility, and increase an individual’s readiness to tolerate the distress commonly associated with ERP.

Current best practices: A brief overview of exposure and response prevention The fundamental principle of exposure treatment involves encouraging clients to approach and engage with a stimulus that elicits a fear response but that objectively is unlikely to cause actual harm. The second premise of ERP is to prevent a ritual, thought, or behavior that functions to reduce anxiety in the presence of a feared stimulus. These rituals, avoidance, or safety behaviors may decrease anxiety in the short term, but research suggests they actually maintain the fear structure long term and may strengthen associations between the fear and the stimulus (Foa, Steketee, Grayson, Turner, & Latimer, 1984). For that reason, the RP portion of ERP is often referred to as the most important aspect of effective treatment. The ERP approach may sometimes also include imaginal or scripted exposures in instances that cannot safely be experienced. Previous theories posit that when exposure therapy works it is due to breaking conditioned fear responses via habituation and desensitization; however, the mechanisms of action for ERP treatment are becoming more clear as studies emerge suggesting that model may not “carve nature at its joints” exactly (see Vinograd & Craske in this volume). In its place, inhibitory learning is emerging as a viable theory, which proposes that instead of fear being extinguished by learning new associations with a feared stimulus, these new associations actually compete with, or inhibit, the older learned fear information (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). This has important implications for treatment, including that the goal is no longer to gradually habituate to a feared stimulus, although that may occur, but rather to generate new learning that can compete with an individual’s preexisting fear associations. Notably, downward extensions of this work to children and adolescents are just beginning to emerge, with some evidence still arguing in favor of habituation (Benito et al., 2018). Either way, this

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information becomes highly salient as one considers whether and how to integrate ACT principles alongside ERP. In general, inhibitory learning approaches conceptualize exposure in terms of respondent and operant conditioning theory. When an individual is presented with a feared stimulus in the absence of the feared consequence (e.g., petting a dog without getting bitten), new inhibitory pathways are solidified in which an individual learns that he/she can experience feared thoughts without the corresponding feared events occurring (i.e., expectancy violations). This new learning is challenging for individuals with anxiety and obsessive compulsive disorder (OCD) to access, as they appear to have deficits in this type of learning task (Greisberg & McKay, 2003), which may require additional trials to encode the new information. Additionally, inhibitory learning principles suggest that individuals can acquire flexible and more adaptive ways of behaving in the presence of feared stimuli (e.g., instead of washing hands repeatedly after touching a doorknob, the individual may choose to continue with his or her day, thus creating a new behavioral repertoire when faced with feared cues). Current research suggests that building a hierarchy and using subjective units of distress (SUDs) are helpful in treatment to a degree, but that treatment may be more effective and generalize to the client’s life more readily when therapists do not follow a strict hierarchy, but rather combine exposures to multiple feared stimuli of varying degrees of difficulty while not relying on the reduction of SUDs during the exposure session as a measure of treatment success (Craske et al., 2008). Treatment that does not follow an organized hierarchy more closely mimics life in that exposures to feared situations outside of the therapy office are frequently unpredictable. The sitting with uncertainty that is required when not following a strict hierarchy may be one mechanism to facilitate generalizing what is learned in ERP to the client’s own life. Importantly, habituation also does not appear to predict treatment outcome, according to the adult literature (Craske et al., 2008). The movement away from reducing SUDs as a treatment goal is reflective of the literature demonstrating that inhibitory learning rather than habituation is an active ingredient in successful ERP therapy (Craske et al., 2008, 2014). Therapists can measure a client’s willingness to experience anxiety at any given moment and observe a client’s increase in flexible functioning in the presence of an anxiety-provoking stimulus, which we will learn is also ACT consistent. Consistent with inhibitory learning, therapists can and should still use SUDs to emphasize expectancy violations (thinking an exposure will be harder or easier than it was in practice). The revamped ERP treatment, despite its reduced emphasis on SUDs or a hierarchy, still requires individuals to confront their most feared

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situations as a core principle of change. Requesting that young clients engage in this type of treatment without the expectation that their anxiety will be reduced while also not permitting the use of maladaptive coping mechanisms (safety behaviors and rituals) is not a particularly inviting petition. These challenges with ERP account for much of the criticism it receives, and are also compelling reasons to integrate ACT.

What is acceptance and commitment therapy? ACT is a cognitive-behavioral approach to psychopathology that was developed nearly 30 years ago and is founded on basic research on human language processes and verbal behavior. Broadly, ACT targets the functions of behaviors, thoughts, and emotions in maintaining patterns that are not helpful to the individual in pursuing his or her values or goals. ACT furthermore aims to increase psychological flexibility, or an individual’s willingness to explore utilizing different behavioral, emotional, or cognitive repertoires when faced with life stressors or feared stimuli. Using the ACT approach successfully requires momentto-moment mindfulness on the part of the therapist as to the function of each behavior or thought in maintaining or undermining an individual’s ability to pursue their values and to behave flexibly in the presence of feared stimuli. ACT is broadly comprised of six core processes that promote psychological flexibility and well-being. These processes are acceptance, cognitive defusion, and awareness of the present moment, self as context, values, and committed action. Acceptance refers to an individual’s ability to allow unwelcome experiences (often internal) to be present without attempting to alter, control, or avoid them. As in cognitive behavior therapies (CBT’s) classic Chinese finger trap example (i.e., the harder you try to pull your fingers out, the more stuck they become, and only by moving your fingers inward can you be released), these control strategies often serve to increase the unwelcome experience rather than effectively diminish it. Cognitive defusion is a process of literal “de fusing” from thoughts or feelings that hook or trap people into unhelpful patterns. We can also think of defusion as adjusting the way we relate to our thoughts and emotions. Instead of letting seductive thoughts or feelings control us, we learn to observe them nonjudgmentally and to notice them without feeling compelled to act on them. Present moment awareness is relatively self-explanatory and refers to purposefully attending to current events, both internal and external, as opposed to focusing on the past or the future. Mindfulness and present moment awareness are closely linked processes. Self as context refers

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to the idea that every person maintains a fundamental sense of self that is stable and consistent upon which the inconsistencies of day-to-day life can be observed, including rapidly changing inner experiences such as emotions and thoughts. Values are akin to cardinal directions, in that they shape behaviors, but are not achievable destinations. We can take steps toward our values, but will never arrive due North. Finally, committed actions are the specific behaviors taken to move an individual toward his or her values. The spirit of these six processes, when utilized by a skilled ACT therapist, is seamlessly woven into the dialogue of the therapy session, and can be used to great effect to shape an individual’s willingness to approach and engage in ERP treatment rather than continued avoidance. As such, ACT is a transdiagnostic approach, but is also readily applied to anxiety disorders and used in conjunction with ERP approaches.

The evidence for acceptance and commitment therapy and acceptance and commitment therapy1exposure and response prevention approaches To date, a handful of meta-analyses examining ACT or ACT constructs (e.g., mindfulness, acceptance) and their association with anxiety and OCD-spectrum disorders exist. A 2014 meta-analysis explored (1) the relationship between psychological flexibility and anxiety and (2) reviewed evidence for ACT with anxiety and OCD-spectrum disorders in adolescent and adult samples (Bluett, Homan, Morrison,

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Levin, & Twohig, 2014). Sixty-three studies met inclusion criteria for the meta-analysis of the association between experiential avoidance and general anxiety symptoms. Of these, 14 included samples of adolescents and young adults (college students). Experiential avoidance was associated with both general and disorder-specific measures of anxiety, including OCD. With regard to the meta-analysis of randomized controlled trials (RCTs) evaluating ACT for anxiety disorders, nine studies (n 5 404) met inclusion criteria (Twohig et al., 2018). Results suggested a nonsignificant small effect size (g 5 0.40, 85%; confidence interval [CI] 5 20.16, 0.96, z 5 1.40, P 5 .16, k 5 9; of note, there was significant variability across studies; Q 5 50.32, df 5 8, P , .001), indicating that ACT fared well relative to comparison conditions (e.g., wait-list, other CBT manualized treatments; Bluett et al., 2014). A meta-analysis of lab-based studies evaluating components of ACT found large effect sizes for defusion, present moment awareness, acceptance, and values (Levin, Hildebrandt, Lillis, & Hayes, 2012), relative to control components, highlighting the clinical utility of these as treatment targets. Modest support was found for psychological flexibility with anxiety only. Additional studies evaluate OCD-spectrum disorders such as trichotillomania, skin picking, and tic disorders. The authors of those studies concluded that, while the efficacy of ACT is comparable to that of CBT, and exposure is first-line treatment, ACT processes may be able to increase willingness to do ERP (e.g., Reid et al., 2017), and ACT interventions may be a more precise way of teaching HOW to do ERP (Bluett et al., 2014). There is a smaller emerging literature evaluating ACT for anxiety and/or OCD in children and adolescents. In a 2015 systematic review by Swain, Hancock, Dixon, and Bowman (2015), only four treatment studies for pediatric anxiety and OCD-spectrum disorders met criteria (Armstrong, Morrison, & Twohig, 2013; Fine, Walther, Joseph, Robinson, Ricketts, & Bowe et al., 2012; Franklin, Best, Wilson, Loew, & Compton, 2011; Yardley, 2012). With regard to scientific rigor, as rated on Ost’s (2008) psychotherapy outcome study methodology rating form (POMRF) scale one study was rated “well above average” (Franklin et al., 2011), two were found to be “above average” (Armstrong et al., 2013; Yardley, 2012), one was “below average” (Fine et al., 2012), and one “well below average” (Brown & Hooper, 2009). All studies showed improved outcomes; in Franklin et al. (2011), ACT was comparable to HRT for trichotillomania with regard to self-rated symptom reports. Lønfeldt, Silverman, and Esbjørn (2017) conducted a systematic review and meta-analysis of “third-wave” approaches (i.e., mindfulness-based cognitive therapy, ACT, and metacognitive therapy) for youth anxiety. The goal of the study was to estimate the mean effect sizes for the

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association of third-wave constructs and child anxiety. They found a moderate effect size for mindfulness, a medium to large effect size for metacognitions, and a large effect size for psychological inflexibility (Lønfeldt et al., 2017). Since 2015, 10 studies on ACT for anxiety and/or OCD-spectrum disorders in children and adolescents have been published; of these, 5 were treatment studies. The largest and most rigorous was by Hancock et al. (2018) who conducted an RCT comparing group-based ACT and CBT treatment versus a wait-list control with parents and adolescents with anxiety aged 12 17 (Hancock et al., 2018). Youth in both conditions experienced a clinically meaningful reduction in symptoms, and ACT was comparable to CBT. Additionally, Azadeh, Kazemi-Zahrani, and Besharat (2015) conducted a small RCT comparing ACT to a wait-list control in a sample of female adolescents with social anxiety disorder. Results indicated that compared to the control group, participants in the ACT group reported significantly improved interpersonal functioning and psychological flexibility. A small body of research also exists suggesting that ACT with parents may be a viable route for treatment as well. A recent open trial evaluated the feasibility of a six-session ACT protocol for parents of children with anxiety or OCD (ACT-PAC; Coyne & Moore, 2015). Twenty-three parents (20 mothers, 3 fathers, mean age 45) of children ages 7 17 with a primary anxiety disorder diagnosis (14 males, 9 females; mean age 13 years) participated in the study. Results suggested that the intervention may decrease parents’ cognitive fusion, allowing them to approach their thoughts about their child’s anxiety disorder in a more psychologically flexible way. Results also indicated that the intervention may reduce children’s internalizing (anxiety and depression) and generalized anxiety symptoms (Levitt, Hart, RafteryHelmer, Graebner, & Moore, 2018). Although preliminary findings regarding ACT efficacy with youth must be interpreted cautiously, they represent a compelling rationale for further study. As such, ACT may be a feasible and comprehensive approach to anxiety and OCD. Certainly more robust examination with larger samples and longer follow up windows is warranted. Taken together, this body of empirical work along with clinical observation suggests that children and adolescents may benefit when ACT is integrated into exposure therapy. When encountering youth who are unable or unwilling to experience and tolerate the intense anxiety that comes with exposure, therapists may find these intervention techniques have particular value for enhancing willingness, flexibility, adherence, and overall symptom reduction. In the sections that follow, we describe in more detail what this might look like in practice.

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How to integrate acceptance and commitment therapy with exposure and response prevention for children and adolescents with anxiety disorders Setting the groundwork for effective treatment Psychoeducation Once an appropriate case conceptualization is complete and data regarding the anxiety disorder diagnosis are gathered, the first few sessions of treatment may focus on psychoeducation and providing a rationale for treatment. Orienting the client to the ACT and ERP model often allows the client to feel hopeful about the prognosis and the efficacy of treatment. While introducing any or all of the six components of ACT can be effective during psychoeducation with both parents and youth depending on the individual case, three in particular may be most relevant to setting the stage for successful treatment: values, cognitive defusion, and acceptance. Values

Exploring values with the children and adolescents early in treatment can be an excellent method of building rapport as it is often an inherently enjoyable activity that clarifies one’s sense of self. Furthermore, discussing values and imagining what life would look like “if therapy worked” also may motivate the client to engage in challenging ERP tasks. One domain where ACT informed ERP diverges from classic ERP is that the exposure tasks are chosen based on values, with the ultimate goal being that the client is able to engage in a valued and meaningful life despite the presence of unwanted internal experiences such as anxiety. The emphasis here is on optimizing functioning rather than identifying the most feared stimuli that may or may not relate to the client’s ability to function or engage in committed actions. Encouraging the client to identify (1) What is valuable and important to him/her and (2) ways that his/her symptoms are currently posing barriers to moving toward those stated values, can bring into focus the importance of treatment and allow the client to recognize that treatment is not a discrete action with a beginning and an end, but rather an ongoing process that can be continued in pursuit of one’s goals even once formal treatment is concluded. ACT is readily adapted for children and adolescents as many of its tenets are based in metaphors. For example, a provider may use the passengers on the bus exercise (Hayes, Strosahl, & Wilson, 1999) when working with adolescents on identifying values and the myriad ways obsessional thinking can inhibit movement toward those

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values. This exercise asks the client to imagine that he/she is driving a bus toward his/her stated values and rowdy passengers are jeering and distracting (obsessions) him/her from the important task of driving. The passengers may even instruct the driver where to go or what to do, but the client’s job is to continue driving the bus in the desired direction with the disruptive thoughts and obsessions along for the ride. Subsequently, we highlight some of the language we like to use in treatment sessions to introduce the concept of values with youth: Therapist: “In today’s session, I want to do something a little different. Instead of only talking about the scary stuff or problems in life, I want to focus on what makes you you. Why do you want to get up in the morning? What makes you feel alive? What makes you tick? Setting aside what parents, friends, teachers, or even therapists think, I want to get to know what you value or find important. Any thoughts right away?” At this point, often children and adolescents will disclose a number of areas of life they find exciting or that give them joy; however, some clients are more reserved and will require coaxing. If that is the case, the therapist can choose from a variety of exercises such as the Yearbook exercise (adapted here from the more commonly known Tombstone exercise), or discussing a favorite movie, but there are certainly others that can be used as well. Below are examples of how these sessions might look: Yearbook exercise—picking up where the previous dialogue ended

Client

“No, I don’t really know what’s important to me, so much of my life has been about my anxiety, and I can’t really imagine life without it.”

Therapist

“That’s okay, that happens. Anxiety is kind of a jerk in that it often tries to take away from us the stuff we like the most. To get us started thinking about what you value, I have an exercise. Now, it may seem a little weird, but stick with me. It’s called the Yearbook exercise, and I want you to imagine how you would want to be remembered by friends and family when you’re graduating high school. What would you want written in your yearbook or as your superlatives? Some people say things like “I want to be remembered by being a good friend,” or “being funny,” but I want you to think about what is most important for you that others remember. Go ahead and jot down some ideas when you’re ready.”

Provide the client a piece of paper. When individuals continue to struggle to identify values, we may use a more abstract technique like discussing a favorite movie, as below.

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Favorite movie exercise (can substitute book or TV show)—picking up where the previous dialogue ended

Client

“I still can’t really think of anything. I don’t know how I want to be remembered or what’s important to me. I guess I just don’t think about this stuff much.”

Therapist

“Okay, let’s shift gears. I get that this can feel pretty overwhelming talking about all these big concepts like values, so instead, why don’t you tell me a little about yourself. Do you have a favorite movie or favorite character in a movie?”

Client

“There is this one movie, “The Perks of Being a Wallflower”, I really like that one.”

Therapist

“That’s a great movie. What made you pick it though? What do you like most about it?”

Client

“Well, I’m not sure really. I guess I like seeing how close the friends are, and that they are kind of the ‘different kids’ in school, but still found each other.”

Therapist

“So it sounds like you might value friendship?”

Client

“Yeah, I guess so. And the music was pretty good too, yanno how it wasn’t so mainstream. I liked that it felt like being different was okay.”

Therapist

“That makes a lot of sense. I really liked those parts of the movie too. So maybe you value acceptance or tolerance? And it sounds like you enjoy music.”

In this way, the therapist begins connecting for the client their interests and hobbies with their values. The next step, once values are identified, is determining what it would look like for the client to actively live those values on a daily basis. Here is where oftentimes a client will naturally not only describe what living their values might look like, but also how anxiety is preventing that. See below:

Client

“Yeah, definitely. Like I want to start a vegan activism group on campus or something. I don’t want to be like everyone else, but I still want close friends and to feel accepted.”

Therapist

“So if you were to live your values of friendship and tolerance, you might start by creating a club on campus that is welcoming to all. What else would it look like to live those values every day? Would you listen to music more too?” (The therapist can and should include interests and hobbies in addition to values). (Continued)

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(Continued) Client

“I would start an activism club, and I would definitely go to more concerts with friends. Or just hang out with friends more in general. That’s where my anxiety is getting in the way. I’m scared of putting myself out there and being judged or of going out to concerts and starting to feel panicky and not being able to escape. What if my friends don’t get it?”

Therapist

“So it sounds like this anxiety is really getting in the way of your life and of you living according to your values. That sounds pretty hard. But one thing that’s important to know about values is that they’re like cardinal directions—North, South, East, West. You can take steps toward them, but you’ll never arrive due North. We are all always just taking steps toward our values, and sometimes we get knocked off course by things like anxiety, but we can get back on track.”

At this point, the therapist has obtained a lot of rich data not only regarding what the client wants his or her life to look like, but also why it does not yet look that way. This is the beginning of a menu of ERP options that is not only based on the client’s fears and anxieties, but also on functionally preparing the client to live according to his/her values, an intrinsically motivating goal for many clients. At the end of the script, notice how the therapist also normalizes the experience of not living one’s values due to anxiety and provides hope, while distinguishing discrete and achievable goals from the values underlying them. Please see sample ERP menu at the end of this chapter for ideas regarding how to structure one. Cognitive defusion

Cognitive defusion is particularly helpful to discuss in the early phase of treatment as it will be referred to frequently during the exposure tasks. A tweak on the common lemon exercise is an especially effective method of demonstrating the power of thoughts to children and adolescents. In the lemon exercise, the therapist encourages the client to sit comfortably with eyes closed and to imagine holding a lemon. To increase present moment awareness, consider slowing down, and providing a detailed description of the lemon including as many sensory experiences as possible (e.g., notice the color of the lemon, the pores on its skin, the feel of its cool waxy weight in your hand, the fresh scent when the lemon is gently squeezed). Then, instruct the client to imagine cutting the lemon open and the associated sensory experiences. Finally, the client should imagine licking or biting into the lemon while the therapist narrates how it might taste, smell, and look. By this point, most clients report that they notice their mouth watered or puckered

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during the exercise, which the therapist can point out is a physical reaction our bodies create in response to thoughts about a lemon; however, there are no lemons in the room. In this way, we demonstrate to our clients that thoughts are powerful and can induce physical and emotional responses that we can regard as interesting mental phenomena without being necessarily factual. This is a first step in noticing thoughts as merely thoughts rather than mandates to act in a prescribed manner. Of note, this exercise is particularly suited to youth who identify their anxiety primarily in psychosomatic ways (e.g., our anxious feelings and thoughts can induce nausea, feeling faint or dizzy, and so forth, just as the thoughts of the lemon caused our mouths to water). Tip: There are many ways of talking about cognitive defusion with youth, the lemon example being just one. To maximize effectiveness, look for thoughts during a session that are serving functionally as barriers to forward progress and target them when discussing defusion. For example, a client may exhibit fusion with a particular thought such as “If I go out with friends, I will panic.” That thought is functionally preventing the client from the experiential aspect of the exposure and the possibility of an expectancy violation in which he or she does not panic. As a first step, labeling for the client that thought fusion is occurring often allows the client to think more objectively about the thought (metacognition), which allows for some amount of defusion (e.g., “is that thought helpful to you in reaching your goals, or is it keeping you stuck not going out and doing what you’d like?” or “there goes your brain, telling you the story it likes to tell you about what you can and can’t do.”) Defusing from thoughts may be a gateway to “bossing back” one’s anxiety as well. Acceptance

A third aspect of ACT that can be helpful to discuss during the early phase of treatment is acceptance, which is a concept closely related to willingness. Paradoxically, learning to accept our internal experiences rather than to fight them can “take the wind out of their sails.” For example, imagine that you are being chased by a lion. The faster you run, the more you activate the lion’s prey drive. You begin to tire from running at top speed and worry that you might be slowing down just enough for the lion to catch you. But wait! There is another way. If you stop and face the lion and perhaps yell at it “HERE I AM!” while waving your arms, the lion will likely stop chasing, surprised, and maybe even take a step back. This example is akin to how our anxiety or fear reacts when we stop avoiding or running from it. We must be willing to face the big scary lion (our anxiety) and accept it in order to fully participate in exposures and gain maximal value from them. During exposure tasks, therapists may frequently ask that the client “lean into” a negative experience, or deepen the anxiety associated with the exposure. To do this requires an

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implicit acceptance of the negative experience and a willingness to allow it to show up despite the discomfort associated with it. The goal in ACT informed ERP is not to eliminate or decrease the distressing thoughts, feelings, or experiences, although that may happen, but rather to learn that we can make room for the distress and be curious about it while continuing to pursue what is most important to us in life despite unpleasant feelings. Put in the language of inhibitory learning, the paralysis that often accompanies distress is a choice, and we can learn to make different choices or to behave flexibly in the midst of discomfort. For both parents and children, introducing the concept of acceptance early also sets the stage for realistic treatment expectations. Anxiety is based in an evolutionary fear response that includes a cascade of hormonal and physical reactions involving the hypothalamic pituitary adrenal (HPA) axis functioning and the sympathetic and parasympathetic nervous system, which control cortisol production, digestion, and pupil dilation among myriad other responses that aide us in quickly responding to a threat in our environment. This evolutionary fight or flight response is an adaptive mechanism; therefore, eliminating the experience of anxiety is not a realistic goal as our emotions are inextricably linked with our biology, although many clients will come to us with that hope. A nice metaphor for children and adolescents that illustrates that anxiety is part of our life and our biology is the weather metaphor, which may look something like this:

Therapist

“Our anxiety and emotional experiences are a little bit like the weather. We aren’t so good at controlling if it’s hot or cold or raining or snowing outside on any given day, but we are generally pretty good at putting on a shorts or a coat or rain boots. So, in treatment, I can’t change the weather, just like I can’t take away your negative emotions or anxieties, but we can together change our relationship to them by putting on a coat, or learning to manage whatever comes up on any particular day. What I want to caution is that sometimes it’s really easy to get in a struggle with the weather, like “I wish it weren’t cold AGAIN today!” but what does that do for us? Not much! Probably just makes us feel badly about another cold day. So let’s work together to notice when we are getting in a struggle with our emotions and trying to control or escape them, and maybe instead we can think about changing our relationship to them when that happens so we can keep on living the lives we want.”

Tip: Acceptance is one of the hardest concepts for clients to grasp, often because they come to therapy hoping we as therapists will “fix” or remove anxiety/discomfort. To hear us say “perhaps this is an area we don’t need to change or fix, but can instead work toward accepting

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and letting those feeling be there” is often disheartening for clients who may feel helpless and hopeless as a result. Be prepared for this reaction, and be ready to discuss how control strategies often backfire, leading to more of the distressing feelings. This work may look like a creative hopelessness intervention. One possible way of navigating this reaction is saying something like this: “We know what your life looks like when we try to control or get rid of your anxiety, we know where that path leads: (insert examples from client’s life here such as staying in bed all day when the scary feelings come up, or losing friendships, feeling bad about self, etc.). But we don’t know what life might look like for you if we stop trying to control how you feel all the time and let it just be there and move forward anyway. I know it may seem strange to welcome in hard feelings instead of trying to make them go away, but can you be curious with me about where this new approach might lead? What might it be like to have all those bad feelings and to take a step toward something you care about today?”

Identifying productive exposure tasks See page 23 for a sample exposure menu. As in traditional ERP, the client and the therapist collaboratively formulate a treatment plan and choose the exposures. In ACT-informed ERP, the tasks chosen are ideally consistent with the client’s goals and values (see script and section on values mentioned previously). Exposures are chosen based not only on what is challenging or anxiety provoking, but also on what is important to the client functionally. Choosing tasks carefully to match the client’s stated values is more likely to be naturally reinforcing, which maintains willingness. Importantly, while performing the exposure task, the therapist should continually bring back the focus to the client’s larger goal. If a child diagnosed with OCD reports a fear of becoming ill due to touching items in the bathroom or associated with it (toilet, wash cloths, sink, toothpaste, and other items traditionally kept in a bathroom), the value may be wanting to be able to go to friends’ homes to play, and if needed, to use their bathrooms without feeling forced to return home to participate in lengthy washing rituals. When formulating the exposure plan, the therapist in this example can capitalize on the child’s values of socializing, having and keeping close friends, and not disrupting play time. A value for a teenager may be the desire to use makeup and a hairdryer in the bathroom when preparing for a date without having to engage in cleaning or washing rituals due to touching “contaminated” bathroom items. While the exposure tasks themselves may be very similar or the same as in traditional ERP therapy, the focus should remain

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on the purpose of the exposure: the client’s stated values and the functional impairment caused by the anxiety. A second way in which ACT treatment for anxiety diverges from a strict ERP approach is in the idea of targeting self-concept via exposures when the self-concept is related to the client’s core fear. When discussing with colleagues, we often think of this as defining a client’s “inner okayness.” This is especially relevant for children and adolescents who are developmentally busy exploring the idea of who they are relative to others. Youth and parents often present with a fear that there is something inherently wrong with them or their child that warrants constant vigilance. In youth with obsessional fears of harming others or of engaging in sexually deviant behaviors, the self-concept can be maladaptive or a source of intense concern. For example, in the case of a young man who sought treatment for OCD because he experienced recurring intrusive violent and detailed images of harming others and of engaging in pedophilia, his self-concept was formulated in connection to his OCD, and he worried he was “at core a bad person.” In cases such as this, exposures related to what it might mean to “be a bad person” including writing scripts about going to prison, committing the feared crimes, and lacking a moral compass may more effectively target his self-concept opposed to more traditional harm exposures (e.g., holding a knife next to a loved one). Coaches and therapists can be instructed to give feedback regarding the harm scripts such as “You must be a monster to be able to imagine actually hurting someone else like this,” which targets the self-concept in addition to the actual harm thoughts by forcing the client to attend to his core fear that something is deeply wrong with him. ERP tasks can be created explicitly to target an adolescent’s maladaptive self-concept, but it can also be implicitly targeted through a simple line of questioning from the therapist such as “what might it mean to not be a hard worker all the time?” or “how would your life change if you weren’t able to be perfect in school?” At times, these simple thought experiments couched as conversations can function much like exposures. Pushing on rigid or tightly held ideas of the self can be a powerful tool for young people to imagine a life in which their symptoms are a part of them but do not define them. The larger goal in including selfconcept in exposures is formulating an idea of the self that encourages increased functioning and committed actions toward goals.

Integrating the family system into treatment The family system is important to consider when treating youth with anxiety disorders. Often, maladaptive patterns of family functioning are present that may maintain the anxiety in the client or undermine treatment goals. Outlining for parents what treatment looks like and how

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they can be involved is an essential first step (e.g., no longer rescuing the child from his or her anxiety, noticing that anxiety itself is not dangerous, etc.); however, the therapist benefits also from an understanding of the role of parenting in child development and may keep this framework in mind when evaluating a family system.

A brief primer on parenting styles Parental psychopathology is predictive of and predicted by child symptoms of psychopathology (Allmann, Kopala-Sibley, & Klein, 2015). As such, in any treatment of children, a basic understanding of the function of parenting behaviors and parental psychopathology as it relates to parenting practices in maintaining pathology is relevant. It should also be emphasized that child psychopathology maintains maladaptive parenting styles (Allmann, Kopala-Sibley, Klein, in preparation), suggesting that treating both parents and children simultaneously may be most beneficial. Baumrind’s (1967, 1971) classic conceptualization of parenting identified three parenting subtypes: authoritative, authoritarian, and permissive behaviors. Authoritative parenting is characterized by high warmth and appropriate amounts of control. Authoritative parents are emotionally supportive but also engage in appropriate limit setting, the use of reasoning, and are consistent in their expectations and rules. Authoritarian parenting includes high control but low warmth. Authoritarian parents maintain high expectations of their children, but are less emotionally supportive or nurturing. Permissive parenting, by contrast, is characterized by high warmth and low control. Permissive parents are emotionally supportive but fail to establish age- and developmentally appropriate boundaries or consistently follow routines. These three parenting styles, or similar constructs, emerge fairly consistently in factor analytic studies (e.g., Lee, Daniels, & Kissinger, 2006; Robinson, Mandleco, Olsen, & Hart, 1995; Robinson, Mandleco, Olsen, & Hart, 2001; Schaefer, 1965; Schludermann & Schludermann, 1970). Although these broad dimensions can be broken down into more specific parenting practices, such as hostility, rejection, warmth, control, structure, and coercion (see Sessa, Avenevoli, Steinberg, & Morris, 2001; Skinner, Johnson, & Snyder, 2005; Wilson & Durbin, 2012a, 2012b), the three broad parenting styles identified by Baumrind (Robinson et al., 1995, 1996) are most frequently included in the parenting literature. In addition, Parker has also found support for an overprotective parenting dimension (Parker, Tupling, & Brown, 1979), which is often studied in the context of anxiety and depressive disorders. Overprotective parents restrict their child’s autonomy via physical or psychological control,

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encourage excessive dependence on the parent, and communicate to the child through their overprotective behavior that the world is a dangerous place. Many studies have reported associations between overprotective parenting and anxiety disorders in youth (Rapee, 1997; Wood et al., 2003), although Gere et al. (2012) suggest that overprotective parenting may also relate to child behavior problems. When evaluating the family system, special attention should be paid to the parenting styles employed as the various styles are associated in the literature with certain outcomes and can yield important information about the function of the child’s behaviors in the family context. For example, authoritative parenting generally relates to positive psychological well-being (Larzelere, Morris, & Harrist, 2013; Baumrind, 1968), and as discussed previously, overprotective parenting is associated with anxiety disorders in youth. As therapists, we can provide psychoeducation to the family regarding appropriate parenting behaviors and the roles of authoritative, authoritarian, permissive, and overprotective parenting styles in maintaining psychopathology. Recent work also suggests that how we frame youngsters’ perceptions of their OCD is important in treatment outcome (Butlin & Wilson, 2018). In addition, how parents view their children’s OCD is also an important predictor of outcome, and is likely also related to their parenting style and mental health. A number of studies to date demonstrate that parents’ perceptions are related to the intensity of the child’s symptoms and treatment outcome (inability to tolerate child distress; Selles et al., 2017). Many of the same processes that are important in treating the child or adolescent will also be relevant when working with the family system. Teaching teenagers and parents to respond to adolescent anxiety flexibly rather than automatically is one of the initial treatment goals we formulate when working with families from an ACT informed ERP framework. Primarily, we aim to scaffold curiosity in parents of their child’s experiences and are careful not to model avoidance or rescuing behaviors with parents. Just as in their children, when anxiety and discomfort show up in parents, they may also over rely on avoidance strategies. It is worth noting that accommodation behaviors generally lead to reductions in child anxiety in the short run while also resulting in reductions of parent anxiety and discomfort. Watching someone who you care about deeply struggle is unpleasant, and many parents instinctively want to “fix” the problem quickly. Unfortunately, this knee-jerk “overprotective” reaction in many parents to protect their children from emotional pain often serves to maintain the anxiety in the long term. Parents may also experience shame at not being able to fix or “effectively parent,” which can lead to catastrophic thinking about what anxiety will do to their child, what others will think of them as parents, fear

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that their child will be damaged, or that anxiety will derail them from ever experiencing good relationships or a good/successful/productive/ happy life. These thoughts can seem very powerful and true, and can also sabotage parents’ ability to effectively manage their adolescent’s anxiety. Tip: Incorporate parents into treatment by allowing them to observe an ERP session without commenting at first. Model for them appropriate approach behaviors and language around anxiety. Next, debrief with parents and allow them the opportunity to ask any questions. At future sessions, invite parents to take the lead in the exposure, while you observe and provide feedback. This scaffolding model for parents is an experiential way to include them in their child’s treatment and provide them confidence that they can duplicate at home what they witnessed in your office.

Troubleshooting Once the exposure tasks are formulated, the therapist can begin the work of ERP treatment; however, it is a rare case that will go exactly as planned. Novel approaches to treatment often require some troubleshooting and a willingness on the part of the therapist to be creative and experimental in approaching challenges. When utilizing ERP, an example we frequently see is the moment when a teenager, faced with imminent ERP, has the thought, “I can’t. It’s too hard.” An ACT clinician, rather than engaging in a tug-of-war battle to get the child to do the ERP, may encourage them to notice the thought as a thought rather than a literal truth (feelings are not facts after all), notice what shows up inside when they have the thought or feeling, and mindfully choose whether to engage in ERP with an awareness of previous behavioral patterns when faced with the same or similar situations (e.g., “is this a familiar feeling? Have you been here before? And what happened when that thought came up in the past?”). ACT allows individuals to defuse from powerful thoughts and feelings and to experience them as simply thoughts that come and go and do not need to function as rules that direct behavior. In that same vein, many ERP therapists struggle to talk to their young clients about how to manage high levels of anxiety that can arise during exposures. Therapists may also experience discomfort bearing witness to their client’s distress without offering an alternative coping mechanism or reassurance. One way to frame higher levels of anxiety for the therapist and the client alike is to recognize it as a more powerful opportunity for learning. Likewise, variety in the intensity of ERP tasks can also be framed as desirable. The therapist can remind the

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client that life does not follow a set hierarchy; therefore, attempting exposures that span a range of difficulty levels may be beneficial in generalizing to life outside of treatment. Another strategy that is helpful when faced with challenges is to use deictic framing, or framing that involves one’s view of the self. Deictic framing promotes “time travel,” or the client’s ability to think about what a future or past version of themselves would advice to the current version of themselves. Often, this motivates bravery-based behaviors instead of avoidance-based behaviors. In a situation where an adolescent boy is stuck and refusing ERP, an ACT informed ERP therapist might ask the client to consider what he will think of himself an hour after successfully completing the exposure, or what he might think of himself an hour after refusing treatment. In this way, the client is able to mentally propel himself through the challenging exposure and to the other side, where he can evaluate his performance and connect with his inherent motivations for seeking treatment. Alternatively, a therapist can ask “what would future you tell present you? Is there any advice you would want yourself to know going into this exposure?” The idea is the same—encouraging the client to change his or her perspective on a situation and thereby granting him or her a degree of cognitive flexibility in approaching the ERP task. With treatment refractory OCD or anxiety disorders, ERP therapists may hear “this won’t work because it’s part of treatment, and it’s not real.” In these cases, an ACT clinician can utilize several strategies, two of which are addressed here. The first is to accept what the client is saying and validate the concerns while also pointing out that in some cases, the goal is not to become more anxious during exposures, but rather to become more curious and willing to explore what emotions do arise. By simply shifting the goal away from increased anxiety, often clients are able to engage more fully in the treatment, and paradoxically, increase their anxiety. The second strategy is to utilize “surprise” ERPs or to gently weave exposures into general conversation with the client so they feel less staged or forced. For example, with a teenager who struggles with perfectionism in school, the therapist may ask her to complete a pop quiz exposure in which the therapist times and grades her performance on a quiz for which she was not permitted to study. The client presumes the exposure is the pop quiz and getting critical feedback from the therapist about her performance on the quiz; however, at the end, the therapist can comment on the girl’s ERP performance and her unwillingness to stop trying to get good grades during exposures. These surprise ERPs can be more effective than the planned ones as they feel more “real” and target the core fear of performing imperfectly whether at school or in treatment. These exposures require creativity and a willingness on the part of the clinician to think outside the box as

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well as the client to trust the clinician and be open to whatever experiences may arise in treatment as in life. Finally, just as in traditional ERP, when utilizing ACT informed ERP, do continue to vary the context of the exposures to optimize treatment outcomes. Consider varying the time of day, the location, or even the child’s mood as a means of generalizing the learning across contexts. Only engaging in exposures every week at 4:00 p.m. in your same office is not going to generalize to outside life as readily as exposures done outside the office, with different coaches if possible, in the home, in restaurants, in the car, or wherever/ whenever the anxiety is most challenging for the client. Try the same exposure when the child is in different mood states to model that even on hard days or when we are not feeling well, we can still do difficult things. As you probably know, treatment gains are not linear, so varying the exposure difficulty and the setting or context is a very powerful tool to enhance learning.

Conclusions ACT helps anxious individuals specifically by fostering exploration of and curiosity about, rather than avoidance of, their experiences through teaching mindfulness and acceptance strategies. Specifically, mindfulness used in the context of exposure supports the development of broad and flexible attention to one’s psychological experiences. Consider that when individuals feel anxiety, they experience physiological arousal, and narrow their attention to threat cues only, to facilitate avoidance or escape. Even in the absence of specific anxiety cues, they might become hypervigilant for these, becoming preoccupied with avoiding any situations that could possibly elicit unwanted experiences (e.g., see anxiety sensitivity literature, Blakely, Abramowitz, Reuman, Leonard, & Riemann, 2017; Raines, Oglesby, Capron, & Schmidt, 2014; Schleider, Lebowitz, & Silverman, 2018). This narrow focus on anxiety results in less sensitivity to other cues in their environment, limiting their ability to learn from those cues. In essence, anxious avoidance is a closed system: individuals simply notice whether they are anxious, or not anxious, or how anxious. Their behaviors are shaped by this—they engage in what “works;” in other words, whatever actions lead to reduced anxiety, to the exclusion of noticing or attending to other cues either in the environment or internally, which fails to support inhibitory learning. This attempt to control anxiety, through focusing one’s attention to it and it alone, entraps individuals. Teaching mindfulness skills; specifically, present moment awareness, acceptance, and defusion during exposure to anxiety provides individuals with replacement behaviors

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and restructured cognitions: curiosity and exploration of interoceptive cues, as well as of the external environment, and treating unwanted experiences not as threats, but as opportunities to explore and to learn. This is not only consistent with traditional exposure-based approaches but also offers a sophisticated way of shaping purposeful attention towards anxiety and anxiety cues. You can think of it as a replacement behavior for distraction, cognitive rituals, and/or “white knuckling” during exposure. It also supports the development of inhibitory learning by reallocating one’s attention more broadly and flexibly (e.g., from anxious/non-anxious to the myriad other available cues from which to learn). An ACT approach requires thinking about exposure differently than more traditional approaches. Rather than conceptualizing the main outcome of exposure as habituation, it seeks to develop flexibility in the presence of unwanted psychological experiences (e.g., anxiety, interoceptive cues, obsessive thoughts). The criterion with which to measure the effectiveness of these behaviors is whether, or to what degree, they move individuals toward pursuits they find meaningful and fulfilling in life, regardless of emotional state. In fostering this goal, ACT requires the acceptance—not simply tolerance or “white-knuckling”—of difficult psychological experiences such as anxiety. This approach is flexible and principles-based, and may support gains over time, as anxiety will very likely wax and wane at different points and in the context of different stressors. Because ACT is a contextual approach, it encourages individuals to approach their fears especially when avoidance costs them valued action. Thus, approaching challenges, especially when it matters most, becomes thoroughly woven into their lives, and as such, comes under the control of powerful, naturally occurring reinforcers. If individuals learn how to “approach” their fears, especially when the cost of avoidance is to lose engagement in activities that are important to them, they may be more likely to maintain treatment gains. Finally, ACT fosters willingness to experience and explore anxiety and OCD in two ways: first, by undermining the functional utility of control strategies (i.e., creative hopelessness); and second, by squarely framing an individual’s behavior in the context of what is most meaningful or valuable to them (i.e., valuing). Undermining control strategies such as avoidance involves helping teens and their parents to experience that while these may work in the short term, they paradoxically increase anxiety and discomfort in the long term. In addition, when teens are crippled by avoidance and anxiety, they may also begin to experience depressed mood and hopelessness about their situation. That hopelessness they feel may represent their active tracking of real contingencies: the more they avoid their anxiety, the worse it gets, and their lives become smaller and more impoverished. Despite their very hard

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work, avoidance ultimately is not workable. This intervention is called “creative hopelessness,” and is the birthplace of curiosity about whether there might be a different way to approach life and its challenges, and if so, what that might be. While undermining control strategies motivates teens to pause and reconsider their use, values discovery and articulation provide a powerful reinforcer for engagement in approach behaviors and curiosity. Valuing, in ACT, refers to the touching upon, again in an experiential way, what one cares deeply about and is meaningful in his or her life. It is framed as a possible, highly desired outcome that can inspire committed action towards that end. For example, you might frame a challenging exposure exercise as a small step towards this larger end. This serves to support engagement in challenging tasks, and sustained approach behaviors, regardless of rising or receding levels of anxiety or OCD symptoms. It may also enhance generalization over time. Exposure therapy is a well-established method of treating anxiety disorders in youth, and there is a growing body of evidence to suggest that ACT is also a useful adjunctive tool therapists can keep in their tool sheds to use independently or alongside ERP. You may even find that it changes the way you think about your own life, fears, and motivations. Sample Menu of ERP Options Background: Fictional client J.M. is a 12 year-old female referred for social anxiety. She is currently attending school, but feels isolated and has few friends. She sits alone at lunch, does not attend middle school socials, and is starting to refuse her extracurricular dance classes. She also refuses to raise her hand in class and will not give required presentations, which are impacting her grades and her participation points. Her core fear is that people will think she is stupid. Below follows a rudimentary sample menu of ERP options linked with J.M.’s stated values (being a good friend, being physically active/healthy, being studious/intelligent). Note that we prefer to call “hierarchies” menus as we believe it better reflects the inhibitory learning model rather than the habituation/desensitization model. Also note that the menu below looks very similar, if not identical to a classic ERP menu. The differences in the method are most noticeable during the treatment itself in how the therapist approaches and talks about anxiety and the feared stimulus, rather than in the structure of the menu or the tasks themselves. Value being targeted—studious/intelligent Raising hand in class at least once per day Raising hand to answer a question that’s easy Raising hand to answer a question that’s hard Raising hand to answer a question and intentionally getting it wrong

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Speak at least once as part of group presentation in History class Take the lead on giving a presentation for next group assignment Volunteer to stand up in class and collect assignments for the teacher Tell a friend you received a worse grade on an assignment than you actually did Value being targeted—friendship Sit with someone new at lunch Invite friend/s to your house once per week Accept invitations with others Prepare for school social Buy a dress (can go out with friends to pick one) Imaginal exposure in advance of school social—imagine being there, tripping, being laughed at, reaction, and so on Intentionally say something “stupid” to friends Going to the bathroom at school even if other girls are already in there Value being targeted—fitness/health Attend at least some portion of dance class once per week Audition for recital Make a mistake in dance class (tell a friend about it?) Ask someone else in the class for help with a difficult move Invite a friend from school to join your dance class Write a script about falling onstage during dance recital audition

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Author Index Note: Page numbers followed by “t” refer to tables.

A

B

Abbott, M. J., 23 24 Abramowitz, J., 88 Abramowitz, J. S., 4, 15, 17, 28 29, 85, 165, 172 173, 259, 262, 280 282, 406, 425 Achenbach, T. M., 169 Aderka, I. M., 193 Agren, T., 59 Albano, A., 70 72 Albano, A. M., 40, 167 168, 193 194, 217, 298 300, 301t, 326 Ale, C. M., 22, 28 29, 160, 171 172 Alexander, J. F., 347 Ali, M. O., 330 Allen, L. B., 362 363 Allmann, A. E., 421 Alverez-Conrad, J., 172 173 Anagnos, J., 183 Andersen, P., 363 Anderson, P. L., 55 56 Anderson, R. A., 28 29 Andersson, G., 363 Andreasen, C. L., 26 Andrews, G., 363 Andrijic, V., 23 Angold, A., 144, 221 222, 405 Antinoro-Burke, D., 158 159 Antony, M. M., 13, 221 222 Arch, J. J., 262 Arendt, K., 23, 100 Arendt, M., 29 Arkowitz, H., 105 Armstrong, A. B., 411 412 Arnett, J. J., 299 303 Arnold, P. D., 249 Arntz, A., 59 60 Arocho, J., 104 Aschenbrand, S. G., 332 Asp, E., 183 Austin, J., 143 144 Avenevoli, S., 421 422 Axelson, D. A., 362 Azadeh, S., 412

Baartmans, J. M., 169 Balooch, S. B., 57 58 Barber, B. K., 327 Barkley, R. A., 40, 347 Barlow, D. H., 14, 108, 118, 139 140, 217, 295, 299, 326 327, 362 363 Barrett, P., 332 335 Barrett, P. M., 40, 74, 143 144, 273, 289 290, 326, 328 Barrios, V., 72 Bath, K. G., 296 297 Battaglia, M., 25 26 Ba¨uml, J., 39 Baumrind, D., 421 422 Bayer, J. K., 23 Beck, A. T., 88 Becker, E. S., 169 Beesdo, K., 143 144, 326 327 Beidas, R. S., 158 159, 324 325 Beidel, D. C., 25 26, 113, 193 194, 217, 324 325 Be´langer, C., 400 Bell, E., 138 Belotti, R., 25 26 Benazon, N., 306, 328, 330, 332, 335 336 Benito, K., 105, 158, 383 384 Benito, K. G., 271, 284 286, 328 330, 335, 407 408 Benjamin, C. L., 246 Bennett-Levy, J., 88 Bennett, K., 85 Bennett, S. M., 77 78, 299 Benoit, K., 193 194 Bentley, K. H., 295 Beresin, C., 262 Bergman Nordgren, L., 363 Bergman, R. L., 72, 75, 113 115, 118 119, 139 140, 246, 274, 328, 330, 332, 334 336 Berman, S. L., 289 290, 324 325 Bernat, D. H., 324 325 Bernstein, G. A., 16, 21, 324 325, 333, 383

433

434 Berryhill, J., 264, 273 275, 280, 284 Besharat, M., 412 Best, E., 411 412 Bickman, L., 334 Biederman, J., 289 290, 324 Biedermann, J., 271 272, 289 290 Biggs, B. K., 24 Bikic, A., 23 Bilek, E. L., 364, 379 Bipeta, R., 330 Bird, T., 362 363 Birmaher, B., 75, 362 Bjo¨rgvinsson, T., 262 Bjork, E. L., 57 Bjork, R. A., 57 Blakely, S. M., 425 Blakey, S. M., 28 29, 105 Blanco, C., 300 302 Bland, M., 363 Blissett, J., 271 272, 276 277 Bloch, M. H., 328 329, 383 Bluett, E. J., 410 411 Bodden, D. H. M., 324 325 Bo¨gels, S. M., 16, 114, 325 327, 346 347 Bolduc, E. A., 324 Bolton, D., 324 Bond, D., 276 277 Bonwell, C. C., 274 Boschen, M. J., 57 58, 85 86 Bouchard, S., 400 Boulter, N., 333 Bouton, M. E., 9 10, 12, 16, 108, 174 Bowe, W. E., 411 412 Bowman, J., 411 412 Boyle, M. H., 113 114 Bradley, B. P., 55 56 Brand, J., 104 Brannan, A. M., 334 Brechman-Toussaint, M. L., 16, 325 327 Breinholst, S., 146, 160 Britt, E., 138 Brody, L., 289 290 Brook, J., 362 363 Brown, F. J., 411 412 Brown, K. W., 342 Brown, L. A., 9 10 Brown, L. B., 421 422 Brown, T. A., 327 Brownlie, E., 296 Buchholz, J. L., 28 29 Buckminster, S., 366 Bugenthal, D. B., 332

Author Index

Burke, A. E., 324 Burklund, L. J., 55 56 Burstein, M., 325 Butlin, B., 422

C Cadigan, J. M., 300 302 Callueng, C. M., 85 86 Calvocoressi, L., 70, 75 76, 262, 306, 328 Campo, J. V., 362 364, 367 Caporino, N. E., 73 75, 329 331, 341 342, 348 Capron, D. W., 425 Cardenas, V., 222 Carl, E., 400 Carpenter, A. L., 115 117, 122, 138 140 Carper, M. M., 9, 25, 100, 331 Carter, A. S., 138 Casey, B., 296 Casey, B. J., 296 297 Caye, A., 405 Cerny, J. A., 324 Chambers, C. T., 183 Chang, S., 75, 246, 328, 330, 332, 335 336 Chansky, T. E., 337 Charney, D., 362 Chatterton, M. L., 23 Chavira, D. A., 114 115 Chemero, A., 89 Chi, T. C., 334 335 Chiu, W., 165 Choate, M. L., 362 363 Chorot, P., 363 Chorpita, B. F., 69, 169, 171 172, 271, 326 327, 383, 406 Chou, T., 138 Choy, C., 172 173, 251, 383 384 Chu, B. C., 146, 325, 337, 364, 379, 406 Clark, D. A., 88 Clark, D. M., 180, 217 Clowes-Hollins, V., 174 Cobham, V., 23 Cobham, V. E., 273, 289, 324 326 Cohan, S., 114 Cohan, S. L., 114 115 Cohen, P., 362 363 Collings, S., 138 Comer, J. S., 74, 115 118, 135, 138 140, 328 329, 331, 336 337 Compton, M., 411 412 Compton, S. N., 22 23, 25 26, 289 290, 324 325, 333 334

Author Index

Conelea, C. A., 296 297 Conlon, E. G., 85 86 Connolly, S. D., 16, 21, 74, 383 Constantino, M. J., 105 Conway, C. C., 8 9, 54 55, 98 99, 247, 271, 407 408 Cooper-Vince, C., 362 Cooper, P., 146, 324 325 Cooper, P. J., 324 325 Copeland, W., 144 Corcoran, K. A., 174 Cornacchio, D., 114 115, 118, 138 Costa, N., 168 Costello, E. J., 144, 221 222, 362, 367, 405 Cowansage, K. K., 59 Coyne, L. W., 412 Craske, M. G., 8 10, 12 16, 54 60, 81, 98 99, 173 174, 247, 271, 285 286, 407 408 Crawford, A. M., 324 325, 333 334 Crawley, S. A., 22 Creswell, C., 74, 146, 324 325, 332 Creswell, J. D., 342 Crick, N. R., 273 Crook, K., 333 Crowe, K., 85 Cukor, D., 327 Culver, N. C., 12 14, 58 59 Cummings, C. M., 221 222, 348 Cunningham, C. E., 113 114 Cunningham, M. J., 23 Curtis, G. C., 249

D da Silva, R. A., 295 Dachinger, P., 6 7 Dadds, M., 333 Dadds, M. M., 74, 326 Dadds, M. R., 40, 273, 289 290, 324 326 Dalgleish, T., 363 Dammann, J. E., 24, 28 29 Daniels, M. H., 421 422 Dar, R., 333 Davies, S., 23 Davis, N. R., 56 57 Davis, T. E., III, 165, 167 173, 175 176 Davison, G. C., 6 7 Dawson, R. W., 7 de Abreu Ramos-Cerqueira, A. T., 334 De Los Reyes, A., 70, 334 335 De Man, A. F., 327 de Rosnay, M., 325 de Vente, W., 346 347

435

Deacon, B., 165, 406 Deacon, B. J., 13, 56 57, 85, 105, 158 159, 172 173, 280 282, 383 384 Dean, S., 138 Demler, O., 165 Diamond, G. S., 346 347 DiBartolo, P. M., 217, 299 Dibbets, P., 59 60 Dickens, C., 362 363 DiGiuseppe, R., 276 277 Dimidjian, S., 96 97, 366 Dixon, A., 411 412 Dixon, L. J., 56 57 Djurhuus, I. D., 23 Dobrean, A., 363 Dodge, K. A., 273 Donovan, C. L., 25 26, 54 55 Douglas, K. V., 70 Dowell, T., 54 55 Dowling, N., 29 Dozois, D. J. A., 105 Drake, K. L., 145, 325, 333 334 Drazdowski, T. K., 73 Drewes, A. A., 274, 276 278 Drost, J., 362 363 Drysdale, A. T., 296 297 Durbin, C., 421 422 Durlak, J. A., 271 272 Dweck, C. S., 345

E Ebert, D. D., 23 24 Echiverri, A. M., 14, 59 60 Edson, A., 331 Edwards, S. L., 274 275, 326 327 Egger, H. L., 144 Ehrenreich-May, J., 299, 364, 379 Ehrenreich, J. T., 332 Eisen, A. R., 145 146 Eisenhower, A. S., 138 Eison, J. A., 274 Eley, T. C., 325 Elizur, Y., 114 Epston, D., 275 276 Erkanli, A., 144, 221 222, 405 Esbjørn, B. H., 146, 411 412 Estes, W. K., 57 Eyberg, S. M., 116 117, 120 121, 121t

F Fairbanks, J. M., 171 172 Faraone, S., 289 290

436 Faraone, S. V., 324 Farchione, T. J., 379 Farrell, L., 262 263, 333 Farrell, L. J., 54 57, 59, 166 167, 184, 328 Farrell, N. R., 105, 158 Feeny, N. C., 172 173 Felix, E., 276 277 Findley, D., 262 263, 289, 396 Fine, K. M., 411 412 Fingerhut, R., 158 159 Finlay-Jones, A. L., 28 29 Fisak, B., 157 158 Jr., 325 Fisak, B. J., 145 Fix, R. L., 85 86 Fizur, P., 11 12, 22, 153, 228 Flannery-Schroeder, E., 22, 41, 221 222, 324 325 Flessner, C. A., 29 30, 328, 330, 335 Foa, E. B., 7 9, 28, 46 47, 54 55, 90, 96 98, 172 173, 271, 407 Foldager, L., 324 Ford, L. A., 289 Forehand, R., 298 Forsyth, B., 367 Fox, S., 305 306 Fox, T. L., 143 144 Francis, S. E., 69, 169, 271, 383, 406 Frank, B., 98 99 Frank, H., 330 Frank, S. G., 6 7 Franklin, M., 411 412 Franklin, M. E., 27 Franks, E. A., 175 176 Frary, R. B., 165 Freeman, J., 26 30, 271 272, 277 Freeman, J. B., 328, 336 338 Freeman, J. C., 275 276 Frobo¨se, T., 39 Fuhrman, T., 271 272 Funderburk, B., 116 117, 120 121, 121t Furr, J. M., 114 115, 118 Futh, A., 330

Author Index

Garcia, A. M., 27, 29 30, 262 263, 324, 333, 336 Garner, L., 85 Geffken, G. R., 29 30, 85 86, 298, 328, 330 Gelder, M. G., 180 Geller, D. A., 21, 245 246 Gerull, F. C., 325 Gilbody, S., 363 Gillan, P., 7 Gillham, J., 327 Ginsburg, G. S., 16, 41, 54 55, 73, 145, 324 325, 333 334, 337 Gloster, A. T., 172 173 Godoy, L., 138 Gola, J. A., 158 159 Gonyea, J. G., 334 Gonzalez, A., 114 115, 363 364 Gordijn, E. H., 107 Gorman, B. S., 262 263, 289, 396 Gosch, E., 41, 221 222, 324 325 Gosch, E. A., 337 Gould, K., 168 Gould, K. L., 26 Gould, R. A., 366 Graebner, E., 412 Granger, D. A., 271 272 Grave, J., 271 272, 276 277 Gray, W. N., 85 86 Grayson, J. B., 407 Graziano, P. A., 85 86 Greden, J. F., 249 Greenley, R. N., 175 176 Gregory, A. M., 325 Greisberg, S., 408 Grills-Taquechel, A. E., 157 158, 193 194, 325 Grills, A. E., 271 272 Grover, R. L., 327 Grunes, M. S., 324 Guerry, J., 300, 301t Guerry, J. D., 300 Gullone, E., 174 Gurley, D., 362 363 Gutenbrunner, C., 114

G Gallagher, R., 118 Gallo, K. P., 362 Gallop, C., 324 325 Gammon, G. D., 324 Garber, J., 362 363, 378 379 Garcı´a-Escalera, J., 363, 367 Garcia, A., 26 27

H Hackman, A., 180 Hagopian, L. P., 165 Hale, L., 329 330 Hale, W. W., III, 327 Hall, G., 11 Hall, K. G., 57

Author Index

Halldorsdottir, T., 22 23, 26, 168 Hambrick, J., 300, 301t Han, S. S., 271 272 Hancock, K., 411 412 Hanna, G. L., 249 Hansen, B., 21 Harris, M., 328 Harrison, J., 228 Harrison, J. P., 11 12, 22, 153 Harrist, A. W., 422 Hart, A., 412 Hart, C. H., 421 422 Harter, S., 277 Hartley, C. A., 296 297 Hathaway, J., 70 Havermans, R., 59 60 Hawley, K. M., 299 Hayes, S. C., 411, 413 414 Healy, L., 328, 332 Hearn, C. S., 25 26 Heberle, A. E., 138 Hedtke, K., 15 16, 221 224, 235 236 Hedtke, K. A., 13, 22, 40, 143 144, 151 153, 326 327, 336 337 Heflinger, C. A., 334 Heimberg, R. G., 217 Hembree, E. A., 7, 172 173 Hennighausen, K., 114 Hensley-Maloney, L., 155 Hermans, D., 10, 56 58, 174 Hermes, H., 392 393 Herpertz-Dahlmann, B., 114 Herren, J., 264, 273 275, 280, 284 Hersen, M. E., 167 Hettema, J. M., 324 Higa-McMillan, C., 271 Higa-McMillan, C. K., 3 4, 69, 383, 406 Hildebrandt, M. J., 411 Hill, C., 23 24 Himle, M. B., 194 195 Hinshaw, S. P., 334 335 Hipol, L. J., 158 Hirshfeld-Becker, D., 345 Hirshfeld-Becker, D. R., 271 272, 289 290 Hirshfeld, D., 289 290 Hirshfeld, D. R., 324 Hitchcock, C., 114 Hoff, A., 228 Hoff, A. L., 11 12, 22, 153 Hoffman, L. J., 300, 303 Hofmann, S. G., 9, 193 194 Højgaard, D. R. M. A., 28 30 Hollon, S. D., 96 97

437

Holm-Denoma, J. M., 144 145 Holmbeck, G. N., 175 176, 299 Holmes, E. A., 59 Holt, C. S., 217 Homan, K. J., 410 411 Hong, N., 118, 139 140 Hood, H. K., 221 222 Hooper, L., 143 144 Hooper, S., 411 412 Hooyman, N. R., 334 Hopko, D. R., 366 Hopko, S. D., 366 Horwitz, S. M., 367 Hougaard, E., 23, 100 Howard, B., 337 338 Howley, J., 59 60 Hu, X. Z., 249 Hudson, J., 26, 221 222 Hudson, J. L., 24 26, 41, 146, 168, 289 290, 324 325 Hughes, A. A., 22, 326 327 Huijding, J., 165 Humphrey, L. L., 333 Hwang, W. C., 146, 325, 406 Hybel, K. A., 28

I Ingman, K. A., 193 194 Ingram, M., 274 275 Ishikawa, Si, 24 Izard, C. E., 277

J Jaccard, J., 324 325 Jackson, D. S., 69 Jacobsen, A. B., 3 4 Jacobson, E., 5 Jaffer, M., 75, 246 Jamesion, L., 55 56 Jensen, A. H., 24 Johnco, C., 145 146, 271 273 Johnco, C. J., 73 74 Johnson, S., 421 422 Johnston, C., 332 Joiner, T. E., 144 145 Jones, A., 158 Jones, M., 26 Jones, M. C., 5 Jones, R. M., 296 Jo´nsson, H., 29 Joseph, J. M., 411 412 Juzi, C., 113 114

438

Author Index

K Kagan, E. R., 25, 100, 331 Kamphaus, R. W., 169 Kane, R. T., 28 29 Karredla, A. R., 330 Kaufer, S., 89 Kaufman, J., 362 Kazdin, A. E., 3 4, 6 7, 157, 271, 323, 334 335 Kazemi-Zahrani, H., 412 Keeler, G., 221 222, 405 Keeton, C. P., 73, 324 325, 333 334 Keller, A. E., 77 78 Keller, M., 246 Keller, M. L., 114 115 Kemp, J. J., 105, 158 Kenardy, J. A., 25 26 Kendall, P. C., 4, 7, 9, 11 16, 22 25, 40 41, 100, 107, 143 147, 151 158, 221 224, 228, 235 236, 241 242, 271 272, 279 282, 289 290, 295, 324 327, 331 332, 336 337, 339, 346 348 Kendler, K. S., 324 Kennedy, S., 326 327 Kennedy, S. J., 274 275 Kennedy, S. M., 299, 379 Kennerley, H., 39 Kerns, C. E., 328 329 Kershaw, R., 55 58 Kessler, R. C., 165, 193, 296, 300 302 Khanna, M. S., 22 24, 337, 347 King, N. J., 165, 171 172, 174, 271 272 Kingery, J. N., 14 16, 154, 365 Kircanski, K., 12 13, 58 60, 297 Kirk, J., 39 Kissinger, D. B., 421 422 Klann, E., 59 Klein, A. M., 169 Klein, D. N., 421 Knappe, S., 143 144 Knight, A., 26 Kodal, A., 25 26 Kopala-Sibley, D. C., 421 Koresko, R. J., 7 Kotchick, B. A., 327 Koudenburg, N., 107 Kozak, M. J., 7 9, 28, 46 47, 54 55, 90, 96 98, 271 Kraemer, S., 39 Krain, A. L., 337 Kratz, H. E., 158 159 Krause, E. D., 327

Krebs, G., 288 Kristensen, H., 74, 113 115 Kristensen, M., 29 Kumpulainen, K., 113 Kurtines, W. M., 16, 289 290, 324 325, 337 Kurtz, S. M. S., 115 116, 118 Kuyken, W., 363 Kvale, G., 21

L La Buissonnie`re-Ariza, V., 25 Labus, J. S., 14, 59 60 Lackey, G. R., 259 Ladouceur, R., 221 222, 241 242 Lampman, C., 271 272 Lang, A. J., 12 13, 57 58 Langley, A., 246, 249 250, 306, 328, 330, 332, 335 336 Langley, A. K., 76, 274, 280 282 Larimer, M. E., 300 302 Larson, M. J., 246 Larzelere, R. E., 422 Last, C. G., 324 Latimer, P. R., 407 Layne, A. E., 324 325 Le, T.-A., 25 26 Leaf, P. J., 367 LeBeau, R. T., 54 55 Lebowitz, E. R., 25, 70, 76, 262 263, 288 290, 306, 328 331, 335, 392 393, 425 Leckman, J. F., 288, 324 LeDoux, J. E., 59 Lee, C. M., 300 302 Lee, F. S., 296 297 Lee, S. M., 421 422 Leff, J., 333 Lehmkuhl, H. D., 298, 330 Leigh, E., 217 Lejuez, C. W., 366 Lenane, M. C., 324 Lenhard, F., 23 24 Leonard, H. L., 324 Leonard, R. C., 29 30, 425 Leonte, K. G., 171 172 Leventhal, J. M., 367 Levin, M. E., 410 411 Levitt, M., 412 Lewin, A. B., 29 30, 145 146, 247 248, 250 251, 262, 271 273, 328, 383 384 Lewinsohn, P. M., 144 145 Lewis, B., 328

Author Index

Lewis, K., 333 Leyfer, O., 362 Li, X., 324 Liao, B., 9 10 Liber, J. M., 324 325 Lickel, J., 165 Lickel, J. J., 13, 56 57, 158 Lieb, R., 324, 326 327 Lieberman, M. D., 55 56 Lillis, J., 411 Lindsay, E. K., 342 Linehan, M., 342 Linehan, M. M., 223 Lipp, O., 57 58 Ljo´tsson, B., 24 Lobovits, D., 275 276 Lockl, K., 154 155 Loew, H., 411 412 Lønfeldt, N. N., 411 412 Lovibond, P. F., 56 57, 174 Lucas, A. N., 363 364 Luckie, M., 324 Luis, T. M., 155 Lyneham, H., 23 Lyneham, H. J., 23 24, 26, 176 178

M Ma, Y., 362 363 Mackintosh, N. J., 11 MacLeod, C., 11, 362 363 MacLeod, K. B., 296 Magill, R. A., 57 Maher-Bridge, M., 362 Majdandˇzic, M., 346 347 Manassis, K., 324 325, 333 334 Mancebo, M. C., 324 Mandleco, B., 421 422 Mann, A., 145 Mansell, W., 362 363 March, J., 21 March, J. S., 27 28, 40, 276, 336 337 March, S., 25 26 Maren, S., 174 Marin, C. E., 71 Marrs Garcia, A., 331 Marrs-Garcia, M. A., 337 Marten, P. A., 217 Martin, G., 347 Masi, G., 144 145 Masia, C. L., 326 327 Massachusetts, L. Y., 366 Massie, E. D., 333

439

Masty, J. K., 118 Mathews, A., 7, 11, 362 363 Matsuoka, H., 24 Mattheisen, M., 249 Mausbach, B. T., 222 May, A., 171 172 Mayer, B., 165 McCarthy, D. M., 22, 160, 171 172 McClure, E. B., 325 McCracken, J., 72, 246 McCracken, J. T., 113, 290, 306, 331 McDonald, D. G., 7 McEvoy, P. M., 362 McGinn, L. K., 327 McGrath, P. J., 183 McGuire, J., 262 263, 289, 396 McGuire, J. F., 26 27, 30, 46 47, 145, 149 151, 153, 172 174, 194 195, 246, 251, 258, 271, 383 385, 391, 399 McHolm, A. E., 113 114 McKay, D., 85, 88, 98 99, 104 107, 160, 323, 408 McKinnon, A., 24 25, 363 McLellan, L., 26 McLellan, L. F., 23 24 McLeod, B. D., 146, 325, 406 McMillan, D., 363 McMurray, N. E., 7 McMurtry, C. M., 183 McNally, R. J., 7 8, 85 86 Meehl, P. E., 97 Meesters, C., 289 290 Meeus, W. H., 327 Mendez, J. L., 155 Mennin, D. S., 221 222 Menzies, R. G., 88 Merckelbach, H., 165, 289 290 Merikangas, K. R., 221 222, 296, 324, 362, 405 Merlo, L. J., 261, 298, 330 331 Mesa, F., 25 26 Mesri, B., 55 56 Metzner, R., 282 283 Meuret, A. E., 9, 15 16 Meyer, J. M., 105 Mian, N. D., 138 Micali, N., 330 Micco, J. A., 332 Mifsud, C., 23 Miklowitz, D. J., 347 Millepiedi, S., 144 Miller, A. L., 223 Miller, W. R., 341

440 Milliner, E., 262 263 Mineka, S., 56 57, 108, 174 Mischel, W., 282 283 Mobach, L., 168 Modell, J. G., 249 Moffitt, C., 169 Moffitt, T. E., 362 Mogg, K., 55 56 Mo¨ller, E. L., 346 347 Monfils, M. H., 59 Montgomery, R. J., 334 Moore, K. W., 155 Moore, P., 412 Moore, P. S., 326, 412 Moore, R., 222 Moos, B. S., 306 Moos, R. H., 306 Morales, M., 105 107 Moreira, J. F. G., 333 Moreno, J., 334 335 Moretz, M. W., 105 107 Morgan, A. J., 23 24 Morgan, J., 329 330 Morris, A., 69 Morris, A. S., 421 422 Morris, T. L., 194, 217, 326 327 Morrison, K. L., 410 412 Mors, O., 362 Morton, T., 271 272 Mountz, J. M., 249 Mucci, M., 144 Mulle, K., 27 28, 40, 276, 336 337 Mundo, E., 249 Munk-Jorgensen, P., 324 Muris, P., 113 115, 139 140, 165, 174, 289 290, 326 327 Murphey, D. A., 332 Murphy, T. K., 29 30, 328 330, 383 384 Murray, L., 146, 324 325 Mustillo, S., 221 222, 405 Myers, K. M., 135 Mystkowski, J. L., 10, 14, 59 60, 173

N Na, P., 171 172 Nakamura, B. J., 69 Nanda, M. M., 327 Narayanan, M., 22 23 Nathan, P., 362 Neale, M. C., 324 Negreiros, A. P. M., 334 Nelson, B., 105 107

Author Index

Nelson, E. A., 56 57 Nelson, E. O., 13 Neumann, D. L., 57 58 Neumer, S.-P., 22 23 Newby, J. M., 363 Newman, L., 13 Neziroglu, F., 324 Niditch, L. A., 334 335 Nielsen, M. D., 26 Nikolic, M., 346 347 Niles, A. N., 55 56 Ninan, I., 296 297 Nissen, J. B., 362 Norcross, J., 172 173 Norton, P. J., 362

O O’Flaherty, A. S., 56 57 O’Malley, K. R., 55 56 O’Neil, K. A., 324 325 O’Neill, J., 249 Oar, E. L., 26, 166 168, 184 Oerbeck, B., 74, 114 115 Oglesby, M. E., 425 Ogliari, A., 25 26 Okajima, I., 24 Olatunji, B. O., 172 173, 180 Ollendick, T., 262 263 Ollendick, T. H., 24, 26, 70, 74, 113 115, 139 140, 165 174, 184, 193 194, 271 272 Olsen, S. F., 421 422 Olson, D. H., 333 Omer, H., 288, 392 393 ¨ st, L. G., 168 169, 171 172, 175, 186 O ¨ st, L.-G., 21, 24, 26 27, 30, 411 412 O Østergaard, K. R., 139 140 Otto, M. W., 366 Overgaard, K. R., 114 115

P Pacilio, L. E., 342 Panza, K. E., 328 329 Parker, G., 421 422 Pasarelu, C. R., 363 Patterson, T. L., 222 Pattwell, S. S., 296 297 Pavlov, I. P., 174 Pear, J. J., 347 Pearce, J. M., 11 Peleg-Popko, O., 333

Author Index

Perednik, R., 114 Peris, T., 221 222 Peris, T. S., 3 4, 12 13, 70 71, 74 75, 77 78, 107, 175, 246, 252 254, 262 263, 290, 296 297, 299, 306, 323, 328, 330 336, 338 343, 345, 347, 383 Perto, G., 324 Peterman, J., 241 242 Peterman, J. S., 9, 14 16, 25, 100, 295, 331 Petukhova, M., 193 Phares, V., 329 330, 334 335 Phillips, J. E., 324 Piacentini, J., 22 23, 72, 75, 77 78, 113 115, 172 173, 246 254, 290, 306, 328, 331, 340 343, 345, 347, 383 384, 391 Piacentini, J. C., 72, 251, 274, 299 Pina, A., 72 Pina, A. A., 155, 324 325 Pincus, D. B., 115 116, 328 329, 362 Pine, D. S., 56 57, 143 145, 326 327, 362 363 Pingali, S., 330 Pinto, A., 326 Pitschel-Walz, G., 39 Platt, S., 334 Podell, J., 337 Podell, J. L., 324 325 Polanczyk, G. V., 405 Pollack, M. H., 366 Poller, M., 114 Porter, M., 26 Postmes, T., 107 Potter, A., 55 56 Poulton, R., 88 Price, M., 55 56 Pripp, A. H., 114 115 Prochaska, J., 172 173 Proctor, K. B., 85 86 Prusoff, B. A., 324 Przeworski, A., 333 Puleo, C. M., 221 222 Puliafico, A., 171 172 Puliafico, A. C., 107, 115 116

R Raaijmakers, Q. A., 327 Raaska, H., 113 Rabian, B., 113 Rachman, S., 7 8, 13, 174 Raftery-Helmer, J., 412 Raines, A. M., 425 Ramsawh, H. J., 367

441

Rao, P. A., 193 194 Rapee, R., 74 Rapee, R. M., 23 24, 40, 74, 146, 167, 171 172, 175 181, 273 275, 289 290, 325 327, 421 422 Rapoport, J. L., 324 Ra¨sa¨nen, E., 113 Rasmussen, P. J., 328 Rathus, J. H., 223 Read, K., 241 242 Read, K. L., 14, 221 222, 241 242 Reales, J. M., 363 Rees, C. S., 28 29 Reid, A. M., 383 384, 399, 411 Reinholdt-Dunne, M. L., 146 Remschmidt, H., 114 Rentrop, M., 39 Rescorla, R. A., 4 5, 13 14 Reuman, L., 28 29, 425 Reuterskio¨ld, L., 168, 186 Rey, J. M., 333 Rey, Y., 71 Reynolds, C. R., 169 Reynolds, S., 143 144 Richard, D., 145 Richard, D. C. S., 172 173 Ricketts, E. J., 411 412 Riddle-Walker, L., 85 86 Riddle, M. A., 73 Riemann, B. C., 425 Riise, E. N., 21 Rinck, M., 169 Rith-Najarian, L., 69, 271, 383, 406 Robinson, C. C., 421 422 Robinson, J., 411 412 Roblek, T., 246, 306, 328, 330, 332, 335 336 Roemer, L., 221 222 Roesch, S., 222 Rohde, L. A., 405 Rollnick, S., 341 Rosario, M. C., 245 246 Rosenbaum, J. F., 289 290, 324 Rosenberg, D. R., 249 Rosenfield, B., 9 Rosenfield, D., 9 Rothbaum, B. O., 7 Rothschild, L. M., 22, 160, 171 172 Rowa, K., 221 222 Rowe, M. K., 12 13, 57 58 Rozenman, M., 74 Rozenman, M. S., 290, 306, 331, 362 Rucker, L., 221 222

442

Author Index

Rudy, B., 273 Rudy, B. M., 145 146, 271 272, 274 275, 289 Russell, C. S., 333 Russell, R. L., 273 Ryan, S., 289 290 Ryan, S. M., 26, 74, 168, 326 Rynn, M., 346 347 Rynn, M. A., 171 172

S Saavedra, L., 72 Saavedra, L. M., 334 335 Sakano, Y., 24 Salkovskis, P. M., 180 Salters-Pedneault, K., 221 222 Salum, G. A., 405 Sampson, N. A., 193 Sanchez, A. L., 114 115, 138 Sanderson, W. C., 327 Sandı´n, B., 363 Santa-Barbara, J., 333 Sapyta, J., 27 30 Sattler, A. F., 70 Scahill, L., 74 75, 262 263, 289, 392 393, 396 Scaini, S., 25 26 Schaefer, C. E., 145 146 Schaefer, E., 421 422 Schiller, D., 59 Schleider, J. L., 25, 327, 333 334, 425 Schlossberg, M. C., 16, 41 Schludermann, E., 421 422 Schludermann, S., 421 422 Schmidt, N. B., 425 Schneider, W., 154 155 Schniering, C., 74 Schwab, J., 300 303 Schwartz, S. J., 299 300 Schwartzentruber, D., 108 Seeley, J. R., 144 145 Seidel, A., 9 Selles, R. R., 422 Sessa, F. M., 421 422 Settipani, C. A., 324 325, 327, 332 Sexton, T. L., 347 Shelby, J., 276 277 Sherman, J. A., 299 Shipon-Blum, E., 114 Shirk, S. R., 167 168 Shonkoff, J. P., 324 325 Shortt, A., 332 Shortt, A. L., 143 144 Sigman, M., 146, 325 326, 406

Silk, J. S., 22 23 Silverman, L. H., 6 7 Silverman, W., 70 72 Silverman, W. K., 16, 70 71, 74, 118, 155, 166 169, 289 290, 324 325, 334 335, 337, 411 412, 425 Simonds, L. M., 330 Singhal, M., 324 325 Siqueland, L., 346 347 Sirbu, C., 165 Skarphedinsson, G., 30 Skinner, E., 421 422 Skinner, H. A., 333 Slavin, L., 69 Sloan, T., 13, 56 57 Small, J. W., 144 145 Snyder, T., 421 422 Somerville, L. H., 296 Somppi, V., 113 Sood, E. D., 155 Sørensen, M. J., 362 Southam-Gerow, M. A., 154, 289 290, 324 325 Speechley, K. N., 367 Spence, S., 23 Spence, S. H., 25 26, 169, 273, 324 325 Sprenkle, D. H., 333 St-Jacques, J., 400 Stallard, P., 146 Stams, G. J. J. M., 326 327 Stanley, J., 138 Statfeld, A., 324 Steerneman, P., 289 290 Stein, M. B., 114 115 Steinberg, D., 324 Steinberg, E., 85 Steinberg, L., 421 422 Steinhauer, P. D., 333 Steinhausen, H. C., 113 114, 324 Steketee, G., 407 Stewart, E., 105, 158, 383 384, 399 Stewart, S., 271 272 Stewart, S. E., 245 246, 262, 328 Stobie, B., 329 330 Storch, E. A., 27 30, 41, 70 71, 105 107, 145 146, 149 151, 153, 160, 174, 194 195, 246, 258, 262 263, 271 273, 288 289, 298, 323, 328 331, 338, 341, 383 385 Stoyanova, M., 12 13 Strauss, C., 329 330 Strege, M. V., 26, 168

Author Index

Strosahl, K. D., 413 414 Su, J., 328 329 Suarez, L., 74 Sugar, C. A., 290, 306, 331 Sugaya, L. S., 405 Sukhodolsky, D. G., 262 263, 289, 396 Sundquist, J., 324 Sundquist, K., 324 Suveg, C., 41, 158, 221 222, 324 325 Svecova, J., 3 4 Swain, J., 411 412 Sweeney, L., 274 275 Sy, J., 13 Sy, J. T., 13, 56 57 Sykes, M., 85 86 Sylvester, C., 74

T Taboas, W. R., 160, 323 Tai, S., 362 363 Tan, P. Z., 391 Taylor, J. H., 22 23, 25 26, 139 Taylor, S., 88 Teichman, Y., 333 Tein, J. Y., 333 334 Telch, M. J., 13, 56 57 Telzer, E. H., 333 Thastum, M., 23, 26, 100 Thomassen, C., 326 327 Thomassin, K., 158 159 Thompson-Hollands, J., 328 331, 335 Thomsen, P. H., 362 Thuras, P. D., 333 Tiede, M. S., 24, 28 29 Tiwari, S., 11 13, 22, 151 153, 228, 235 236, 240 Tolin, D. F., 105 Tompson, M. C., 331 Tone, E. B., 55 56 Toner, P., 363 Toppelberg, C. O., 114 Torgersen, H., 74 Torp, N. C., 28, 262 263, 324 Torres, A. R., 334 Torresan, R. C., 334 Treanor, M., 8 9, 54 55, 98 99, 247, 271, 407 408 Trufan, S. J., 328 Tryon, W. W., 118 Tsigara, N., 325 Tull, M. T., 221 222 Tupling, H., 421 422

443

Turner, R. M., 407 Turner, S. M., 193 194, 217, 324 325 Twohig, M. P., 15 16, 410 412 Twomey, C., 363

U Umemoto, L. A., 169 Urcelay, G. P., 174, 181

V Valiente, R. M., 363 van Brakel, A. M., 326 327 van den Boom, D. C., 346 347 van den Broek, P., 273 van den Heuvel, O. A., 249 van der Bruggen, C. O., 326 327 van Dongen, L., 326 van Melick, M., 326 327 van Niekerk, R. E., 169 van Zwol, L., 165 Vannest, K. J., 169 Vansteenwegen, D., 12, 57 58 Varela, R. E., 155, 334 335 Vaughn, C., 333 Ve´lez, C. E., 327 Vervliet, B., 8 10, 13 14, 54 55, 58 59, 98 99, 247, 271, 407 408 Viana, A. G., 113, 118 119, 126 Viar-Paxton, M. A., 180 Vickers Douglas, K., 28 29 Victor, A. M., 324 325, 333 334 Vigerland, S., 23 24, 171 172 Villabo, M. A., 22 25 Vitorino, C. N., 334 Voort, J. L. V., 3 4 Vorstenbosch, V., 13

W Wagner, A. R., 4 5 Walkup, J., 72 74, 76 Walkup, J. T., 22 23, 40, 77 78, 139, 221 222, 241 242, 402 403 Walters, E. E., 165 Walther, M., 271, 284 286 Walther, M. R., 411 412 Walz, J., 324 Wang, Z., 21 22, 383 Warren, S. L., 333 Waters, A., 262 263 Waters, A. M., 54 60, 145, 289 Waters, W. F., 7

444 Weems, C. F., 289 290, 324 325 Weersing, V. R., 289 290, 324 325, 362 364, 366 367, 379 Wei, C., 14, 221 222, 241 242 Weissman, M. M., 324 Weisz, B., 271 272 Weisz, J. R., 3 4, 271 272, 299 Wells, A., 180 Wergeland, G. J., 21 Wertz, F. J., 91 92 Westbrook, D., 39 Westbrook, R. F., 174 Westra, H. A., 105 Wever, C., 333 Whaley, S. E., 326 Wharton, T. A., 289 Wheatcroft, R., 332 Wheaton, M. G., 259 Whiteside, S. H., 160 Whiteside, S. P., 3 4, 145, 158, 160, 171 172, 194, 323, 383 384 Whiteside, S. P. H., 22, 24, 28 29, 70, 85, 105, 160, 280 282 Whiting, S. E., 171 172 Wickramaratne, P. J., 324 Wierson, M., 298 Wignall, A., 23, 176 178 Wijsbroek, S. A., 327 Wilcoxon, L. A., 6 7 Willetts, L., 324 325 Wilson, C., 143 144, 422 Wilson, K. G., 413 414

Author Index

Wilson, S., 411 412, 421 422 Wittchen, H. U., 193, 326 327 Wolitzky-Taylor, K. B., 15 16, 180 Wolk, C. B., 336 Wolpe, J., 5 7, 90, 148 149, 223 224, 251 252 Wood, J. J., 72, 146, 325 327, 406, 421 422 Woods, P., 274 Wootton, B. M., 28 29 Wu, K., 249 Wu, M. S., 29 30, 85 86, 172 173, 251, 328 330, 383 384

Y Yardley, J., 411 412 Yaryura-Tobias, J. A., 324 Yerramilli, S. S. R. R., 330 Yim, L., 169 Young, B. J., 194 Yuan Li, S. S., 363

Z Zaslavsky, A. M., 193 Zavrou, S., 145 146, 271 273 Zbozinek, T., 8 9, 54 55, 98 99, 247, 271, 407 408 Zbozinek, T. D., 12 13, 59 Zitterl, W., 263 Ziv, R., 333 Zoellner, L. A., 172 173 Zohar, A. H., 245 246

Subject Index Note: Page numbers followed by “f” and “t” refer to figures and tables, respectively.

A ABCT. See Association of Behavioral and Cognitive Therapies (ABCT) Abstract technique, 414 Acceptance, 409 410, 418 419 Acceptance and commitment therapy (ACT), 405, 409 410 clinician, 423 evidence for ACT and ACT 1 exposure and response prevention approaches, 410 412 exposure and response prevention, 407 409 identifying productive exposure tasks, 419 420 integrating ACT with ERP for children and adolescents, 413 419 acceptance, 417 419 cognitive defusion, 416 417 effective treatment, 413 419 psychoeducation, 413 419 values, 413 416 integrating family system into treatment, 420 421 primer on parenting styles, 421 423 troubleshooting, 423 425 Accommodation, 100 family, 262, 328 332, 395 396 Acrophobia, 399 400. See also Phobia ACT. See Acceptance and commitment therapy (ACT) ACT protocol for parents of children with anxiety or OCD (ACT-PAC), 412 Active learning, 274 of behavior, 121 122 ADHD. See Attention-deficit hyperactivity disorder (ADHD) ADIS. See Anxiety Disorders Interview Schedule (ADIS) ADIS-C. See Anxiety Disorders Interview Schedule for Children (ADIS-C) Adolescents/adolescence, 154, 193 196

advantages of transdiagnostic approach with, 365 366 developmental stage, 296 299 developmentally appropriate treatment models, 299 implications for exposure therapy, 296 297 maintaining motivation, 298 299 working with parents in adolescent exposure therapy, 297 298 exposure therapy, 14 16 for OCD, 245 246 exposure with, 295 trouble-shooting exposures with, 384 393 Adverse events, 22 American Psychological Association (APA), 3 4 Anxiety, 42 43, 199 202, 324, 362 alarm, 119 components, 222 223 domains, 72 73 habituation process, 284 monster, 341 rating scale, 280 282 reduction, 119 scale, 280 282 three-component model of, 199 youth and parent report of symptom severity and impairment, 74 76 Anxiety disorders, 14 15, 114, 288, 406 clinical characteristics impact on treatment comorbid disorders, 26 family factors, 25 social anxiety disorder, 25 26 specific phobias, 26 delivery format considerations for treatment group or individual therapy, 24 25 remote treatment, 23 24 treatment intensity, 24

445

446

Subject Index

Anxiety disorders (Continued) in younger children, 273 Anxiety Disorders Interview Schedule (ADIS), 70 72, 304 ADIS-IV-C/P, 167 168 Anxiety Disorders Interview Schedule for Children (ADIS-C), 118 Anxiety-producing exposures, 194 195 Anxiety-provoking activities, 117 Anxiety-provoking situations, 197 199 Anxious modeling, 325 Anxious youth, psychoeducation for exposure therapy with, 40 42 APA. See American Psychological Association (APA) Appropriate coping modeling, 134 ARC. See Assisted referral to care (ARC) ASD. See Autism Spectrum Disorder (ASD) Assertiveness training, 205 207 Assisted referral to care (ARC), 367 Association of Behavioral and Cognitive Therapies (ABCT), 401 402 Attention-deficit hyperactivity disorder (ADHD), 22 23, 26 symptoms, 168 Authoritarian parenting, 421 422 Authoritative parenting, 421 422 Autism Spectrum Disorder (ASD), 215 216 Avoidance, 363 364 behaviors, 194 hierarchy creation, 147 148 Awareness-building exercises, 263 264

B BASC. See Behavior Assessment System for Children (BASC) BAT. See Behavioral Assessment Task (BAT) BBT. See Brief behavioral therapy (BBT) Behavior Assessment System for Children (BASC), 169 Behavior therapy (BT), 138 139, 362 363 Behavior Therapy Training Institutes (BTTI), 401 402 Behavior(al) assessment, 169 170 avoidance, 194 description, 121t difficulties, 288 289 functioning measures, 304 306 management, 347 Behavioral Assessment Task (BAT), 169 170

Behaviorism, 4 5 Benzodiazepine, 13 Between-session exposure assignments, 101 102 Blood-injection injury (BII), 165 166 Brainstorm, 159 Brave behavior model, 125, 134 Brief behavioral therapy (BBT), 366. See also Cognitive behavioral therapy (CBT) development, 366 evidence base, 367 general considerations for implementation, 376 378 managing complex symptom presentations, 376 378 implementation, 367 369 for youth anxiety and/or depression session summary, 368t BT. See Behavior therapy (BT) BTTI. See Behavior Therapy Training Institutes (BTTI) Building session(s), 215 216

C CAIS-/CP. See Child Anxiety Impact Scale Parent/Child (CAIS-/CP) Camp Cope-A-Lot format, 23 24 CAMS. See Child/Adolescent Anxiety Multimodal Study (CAMS) Caregivers, trouble-shooting exposures with, 393 399 Catastrophizing, 202 CBCL. See Child Behavior Checklist (CBCL) CBGT-A. See Cognitive-behavioral group therapy for adolescents (CBGT-A) CBT. See Cognitive behavioral therapy (CBT) CDI skills. See Child-Directed Interaction skills (CDI skills) Child anxiety, 284 developmental level, 154 155, 273 factors, 107 108 interests, 277 refusing treatment, 289 Child Anxiety Impact Scale Parent/Child (CAIS-/CP), 76 Child Behavior Checklist (CBCL), 169 Child obsessive compulsive impact scale revised (COIS-R), 75 Child-Directed Interaction skills (CDI skills), 120, 121t

Subject Index

Child/Adolescent Anxiety Multimodal Study (CAMS), 22 23, 139 Childhood SM, 115 117 assessment, 117 119 challenging issues, 137 139 comorbidity, 138 education accommodations, 137 medication, 138 139 coping strategies, 128 129 fear hierarchies, 129 132, 130f graduated exposure activities, 129 132 homework and promoting generalization in community, 132 137 psychoeducation, 119 125 real-time parent coaching, 119 125 reinforcement, 125 126 shaping, 128 stimulus fading, 126 127 Children, 194 196 advantages of transdiagnostic approach with, 365 366 exposure therapy, 14 16 for OCD, 245 246 with SM, 128, 132 133 trouble-shooting exposures with, 384 393 Children’s Yale Brown Obsessive Compulsive Scale (CYBOCS), 74 75 Chronological age, 154 Chronology, 248 260 conducting exposures, 255 259, 256t constructing fear hierarchy, 251 252 coping skills, 252 254 exposure hierarchy for checking compulsions, 253t psychoeducation components, 248 251 relapse prevention, 260 Classical conditioning, 4 5 theory, 174 Clinical deterioration. See Self-harm deterioration Clinician discomfort, 158 Clinician severity rating (CSR), 71 72 Clinicians, 145 146, 151 153, 156 157, 273 clinician-administered interview, 304 trouble-shooting exposures with, 399 402 access to education/training/ experience to conduct exposures, 401 402 access to resources to conduct exposures, 399 402

447

Cognitive behavioral therapy (CBT), 3 4, 15 16, 21, 25 26, 40, 69, 85, 143 144, 171 172, 221 222, 271, 323, 361 363, 383. See also Brief behavioral therapy (BBT) key interventions Cool Kids program, 23 Coping Cat program, 22 23 protocols, 289, 324 325 for youth anxiety disorders, 22 for youth obsessive compulsive disorder, 26 27 Cognitive defusion, 409 410, 416 417 Cognitive development, 115 116 Cognitive distortions, 202 203 Cognitive restructuring, 15 16, 202 204, 254, 365 Cognitive-behavioral approaches, 217, 406 Cognitive-behavioral group therapy for adolescents (CBGT-A), 217 Cohesion and conflict subscales of FES, 306 COIS-R. See Child obsessive compulsive impact scale revised (COIS-R) Committed actions, 409 410, 413, 420 Communication, 347 Comorbid(ity), 70 71, 138 disorders, 26, 30 psychopathology, 262 263 Conditional response (CR), 4 5 Conditional stimulus (CS), 4 5, 12 13, 55 56 Confederates, 212, 227 228, 311 312 Contamination, 135 Context renewal, 10 Continued exposure practice, 211 213 Cool Kids manual, 175 176 Cool Kids Outreach Program, 23 24 Cool Kids program, 23, 178 181, 184 Cool Little Kids Online, 23 24 Coping Cat Program, 15 16, 22 23, 221 222 Coping skills, 69, 252 254 Coping strategies, 128 129 Corrective learning, 59 60 Counterconditioning, 6 7 CR. See Conditional response (CR) CS. See Conditional stimulus (CS) CSR. See Clinician severity rating (CSR) Cue-based fear extinction learning, 296 297

448

Subject Index

CYBOCS. See Children’s Yale Brown Obsessive Compulsive Scale (CYBOCS)

D Daily report card (DRC), 136 137 Deep breathing, 234 235 Deep muscle relaxation, 5 Deepened extinction, 13 14 Dentist phobia, 178 Depression, 362, 378 379 transdiagnostic brief behavioral therapy for, 366 369 Developmental level of child, 154 155 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5), 70 71, 144, 165 166, 304 Diagnostic categorizations, 361 362 Diaphragmatic breathing, 371 Differential attention strategy, 343 Distraction techniques, 128 129 Distress, 249 250 ratings, 377 tolerance, 223, 234 235, 285 286 Dog phobia, 178 DRC. See Daily report card (DRC) DSM5. See Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5)

E Education accommodations, 137 Emerging adulthood changing role of parents, 302 303 developmental phase of, 299 304 developmental tasks, 300, 301t developmentally appropriate treatment models, 303 304 implications for mental health and exposure treatment, 300 302 implications for parent work with young adults, 303 Emetophobia, 85 86, 399 400 Emotion characters, 277 278 Emotional processing theory (EPT), 7 8 Emotional spirals, 369 370 EPT. See Emotional processing theory (EPT) ERP. See Exposure and response prevention (ERP) Evidence-based assessment, 70, 167 168 Excessive control. See Parental overcontrol

Excitatory associations, 9 10 Expectancy violation, 10 11 Exposure activities. See Exposures Exposure and response prevention (ERP), 44 46, 53 54, 246, 331, 405 406 Exposure tasks, 54, 337 338 designing, 282 284 after exposure, 153 before exposure, 149 151 features, 147 149 fear and avoidance hierarchy creation, 147 148 SUDs, 148 149 implementation, 151 153, 239 240 sample GAD fear hierarchies, 241 types, 146 147 Exposure therapy, 3 4, 10 13, 42 44, 81, 145 147, 149 153, 158 159, 186, 195, 197 assessment, 117 119 challenges with, 384 for children and adolescents, 14 16 description and rationale, 145 146 habituation model, 7 9 implementing, 48 54 implications for, 296 297 inhibitory learning model, 9 10 maximizing exposure therapy outcomes, 54 60 for OCD in children and adolescents, 245 246 chronology and components of, 248 260 comorbid psychopathology, 262 263 factors complicating, 260 264 family accommodation, 262 insight and motivation, 261 surreptitious compulsions and therapy-interfering behaviors, 263 264 psychoeducation, 39 46, 60 62 for SAD, 143 145 specific techniques, 13 14 strategies to enhance arousal and engagement during, 57 58 systematic desensitization, 4 7 trouble-shooting exposures with children and adolescents, 384 393 with clinicians, 399 402 with parents and caregivers, 393 399 Exposure-based CBT, 21, 221 222

Subject Index

anxiety disorder treatment clinical characteristics impact, 25 26 delivery format considerations, 23 25 obsessive-compulsive disorder (OCD) CBT for youth OCD, 26 27 clinical characteristics impact on, 29 30 delivery format considerations for treatment, 28 29 interventions for, 27 28 youth anxiety disorders CBT for, 22 examples of key interventions, 22 23 Exposure-based interventions, 85 barriers to successful exposure therapy, 104 108 child factors, 107 108 therapist factors, 105 107 basic illustrative case, 86 88 determining presence of phobia, 87 88 key symptoms and genesis of feared situations, 88 developing and implementing exposure exercises, 94 104 first exposure exercise, 96 97 making most of exposure, 99 rewarding exposure, 100 104 between session exercises, 100 therapist behavior during exposure, 97 98 developing hierarchy, 90 94, 102 104 phenomenological exercise, 91 92 SUDS, 90 planning for termination, 108 target stimuli identification, 88 89 Exposures, 194 195, 207 208, 309 311, 383 with adolescents and young adults, 295 assessment, 304 307 clinical examples, 314 320 course of treatment, 315 320 developmental phase of emerging adulthood, 299 304 developmental stage of adolescence, 296 299 step-by-step treatment approach, 307 314 targets, 310t exercises, 3 4, 100 exposure-based CBT, 383 exposure-based therapy, 271 272 exposure-oriented therapies, 299

449

frameworks, 284 implementation, 284 288 model, 276 277 obstacle course, 285 286 session(s), 175 treatment, 174, 246 247 in vivo, 173 Extinction-based (inhibitory) learning, 174

F Fade-in strategies, 126 127, 135 136 FAH. See Fear and Avoidance Hierarchy (FAH) False alarms, 42 43 Familial inclusion, 247 248 Family accommodation, 262, 328 332, 395 396 dynamics, 289 290 factors for anxiety disorder treatment, 25 for OCD, 29 30 family-based CBT for youth anxiety, 324 325 family-inclusive treatments, 331 functioning, 333 334 involvement, 143 146, 273 system, 420 421 into treatment, 420 421 therapy, 290 Family Accommodation Scale (FAS), 75, 306 Family Accommodation Scale Anxiety (FASA), 76, 306 Family Environment Scale (FES), 306 Family members in exposure therapy, 323 family characteristics linked to youth anxiety and treatment outcomes, 324 334 caregiver strain/family burden, 334 family accommodation, 328 332 family functioning, 333 334 modeling and verbal transfer of information, 325 326 parental cognitions about child anxiety, 332 parental overcontrol, 326 327 psychopathology in family, 324 325 practical recommendations, 334 348 addressing family responses to OCD/ anxiety symptoms, 339 346 attending to family context during assessment, 334 336

450 Family members in exposure therapy (Continued) choosing treatment format, 336 338 orienting families to treatment, 339 FAS. See Family Accommodation Scale (FAS) FASA. See Family Accommodation Scale Anxiety (FASA) Fear, 42 43 acquisition, 4 5 of spiders. See Acrophobia structure, 7 8 of vomiting. See Emetophobia Fear and Avoidance Hierarchy (FAH), 304 Fear hierarchy, 129 132, 130f, 147 148, 175, 280 282. See also Symptom hierarchy constructing, 251 252 creation, 147 148 development, 223 225 future-oriented GAD worries, 226t, 227t GAD worries about changes in plans and new situations, 232t about health of self/others, 233t about local affairs, 231t about world affairs, 230t performance/perfectionism GAD worries, 228t safety-related GAD worries, 229t school-related GAD worries, 224t, 225t Fear Survey Schedule for Children Revised (FSSC-R), 169 FES. See Family Environment Scale (FES) Fighting fear by facing fear, 176 178, 179t Filtering, 202 First exposure practice, 207 211 504 Plan, 137 FSSC-R. See Fear Survey Schedule for Children Revised (FSSC-R) Functional analysis, 77 78 Future-oriented GAD worries, 226t, 227t, 237 239. See also School-related GAD worries

G GAD. See Generalized anxiety disorder (GAD) GBAT. See Group Behavioral Activation Therapy (GBAT) Generalization in community, 132 137 children with SM, 132 133

Subject Index

practices, 133 135 question cards, 133 135 in schools, 135 137 Generalized anxiety disorder (GAD), 221 222, 314 315 before beginning exposures, 222 223 exposure tasks implementation, 239 240 fear hierarchy development, 223 225 planning exposures future-oriented GAD worries, 237 239 school-related GAD worries, 226 237 problem-solving potential difficulties, 240 241 sample GAD fear hierarchies and suggested exposure tasks, 241 Genetic and environmental factors, 114, 146 Glossophobia, 400 Graduated exposure activities, 129 132 Group Behavioral Activation Therapy (GBAT), 379 Group therapy, 24 25 Guided imagery exercises, 371

H Habituation, 48, 126, 278 279 model, 7 9, 194 195 Harm scripts, 420 Hierarchy. See also Fear hierarchy; Symptom hierarchy avoidance, 147 148 development, 90 94, 102 104 phenomenological exercise, 91 92 SUDS, 90 joint, 340 mini-hierarchy, 102 104 Highly context-dependent, 181 Homework compliance, 397 Hypothalamic pituitary adrenal axis (HPA axis), 362 363, 418

I IEP. See Individualized Education Plan (IEP) IGBT. See Intensive group behavior treatment (IGBT) Imaginal exposures, 146 147, 173, 257 Imaginative variation, 91 92 Immersive VR headsets, 400 In vivo exposure, 97 99, 400 401 In-session exposures, 157 158 Individual CBT, 324 325

Subject Index

Individual therapy, 24 25 Individualized Education Plan (IEP), 137 Inhibitory learning, 48 framework, 81 model, 9 11, 14 16, 98 99 principles, 408 Intensive group behavior treatment (IGBT), 114 115 Intensive treatment models, 139 140 for OCD, 29 Internalizing “cluster”, 362 International Obsessive Compulsive Disorder Foundation Genetics Collaborative (IOCDF-GC), 249 International OCD Foundation (IOCDF), 401 402 Interoceptive exposure, 173 Interviews, 70 74 Intolerable distress, 11 IOCDF. See International OCD Foundation (IOCDF)

J Joint hierarchy, 340 Jumping to conclusions, 202

L Labeled praise, 121t Launching Emerging Adulthood Program (LEAP), 303, 305 Launching Emerging Adults Form (LEAF), 305 306 Lemon exercise, 416 417 Likert-type scale, 72 73

M Maladaptive coping mechanisms, 408 409 Manualized CBT, 27 Maternal anxiety, 324 325 Mayo Clinic Anxiety Coach iOS app, 28 29 Medication, 138 139 Meta-analysis, 383, 405 MI. See Motivation interviewing (MI) Mind reading, 202 Mini-hierarchy, 102 104 Misappraisal of exposure distress, 385 390 Motivation interviewing (MI), 313 Mouse models, 296 297 Multiinformant assessment, 334 335 Multiple stimuli representative of feared stimulus, 57 58

451

N Narrative therapy, 275 276 National Institute of Mental Health (NIMH), 324 Natural environment type (NET), 165 166 “Near-neighbor” cluster, 362 Negotiation trap, 156 157 NET. See Natural environment type (NET) Neutral effect on anxiety, 284 NIMH. See National Institute of Mental Health (NIMH) Nordic long-term OCD treatment study (NordLOTS), 28 Normative separation distress, 144

O Obsessive-compulsive disorder (OCD), 21, 40, 69, 245 246, 272, 306, 324, 383 addressing family responses, 339 346 eliminating secondary gain, 344 expanding families’ toolkit, 347 managing difficult episodes, 342 343 processing emotions, 339 rewarding effort, 345 346 targeting other familial influences on anxiety, 346 347 terminating treatment, 348 validating feelings and prompting coping, 344 345 withdrawing family accommodation, 339 342 CBT for youth, 26 27 chronology and components of exposure therapy, 248 260 clinical characteristics impact comorbid disorders, 30 family factors, 29 30 delivery format considerations for treatment intensive treatments, 29 remote treatment, 28 29 exposure therapy in children and adolescents, 245 246 factors complicating exposure therapy, 260 264 interventions NordLOTS, 28 POTS, 27 POTS Jr., 27 28 treatment approach, 246 248 youth and parent report of symptom severity and impairment in, 74 76

452

Subject Index

Occasional reinforcement, 13 14 OCD. See Obsessive-compulsive disorder (OCD) OCD Collaborative Genetics Association Studies (OCGAS), 249 OCD-spectrum disorders, 411 OCGAS. See OCD Collaborative Genetics Association Studies (OCGAS) One session treatment (OST), 26, 171 172 Open brainstorming, 79 OST. See One session treatment (OST) Overgeneralization, 203 Overprotective parents, 421 422 Overwhelming anxiety, 300 302

P PABS. See Parental Attitudes and Behaviors Scale (PABS) Panic disorder, 13 14 Parent Family Interaction Treatment model (PFIT model), 306 Parent-Directed Interaction skills (PDI skills), 138 Parental Attitudes and Behaviors Scale (PABS), 306 Parental overcontrol, 326 327 psychological control, 327 Parental/parents, 145 146 accommodation, 107, 114, 222 223, 328 anxiety, 324 325 attitudes, 157 158 behaviors, 157 158 changing role of parents, 302 303 cognitions about child anxiety, 332 control, 155 factors, 289 290 and family functioning measures, 306 307 implications for parent work with young adults, 303 involvement, 378 parent-report measures, 335 parent-reported anxious modeling, 325 primer on parenting styles, 421 423 psychopathology, 421 report of symptom severity and impairment, 74 76 in treatment sessions, 312 314 trouble-shooting exposures with, 393 399 working with parents in adolescent exposure therapy, 297 298

Parent Child Interaction Therapy (PCIT), 116 117 Parent Child Interaction Therapy-Selective mutism (PCIT-SM), 117 PARS. See Pediatric Anxiety Rating Scale (PARS) Passive learning, 274 Patient resistance to completing exposures, 390 393 short-term exposure distress, 391 symptoms, 391 393 Pavlovian conditioning, 4 5, 9 10 PCIT. See Parent Child Interaction Therapy (PCIT) PCIT-SM. See Parent Child Interaction Therapy-Selective mutism (PCIT-SM) PDI skills. See Parent-Directed Interaction skills (PDI skills) Pediatric anxiety and depression, transdiagnostic BBT for, 366 369 Pediatric Anxiety Rating Scale (PARS), 72 74 Pediatric OCD, 246 symptoms, 328 Pediatric OCD treatment study (POTS), 27, 246 POTS Jr., 27 28 Permissive parenting, 421 422 PFIT. See Positive family interaction therapy (PFIT) PFIT model. See Parent Family Interaction Treatment model (PFIT model) Phenomenology of SAD, 215 216 Phobia, 87 88. See also Specific phobia dentist, 178 dog, 178 social, 71, 361 362 Physical feelings, 198 Physical sensations, 173 Pleasant activity scheduling, 366 Pop quiz exposure, 424 425 Positive family interaction therapy (PFIT), 331, 338, 345 Postexposure consolidation of learning, 11 12 POTS. See Pediatric OCD treatment study (POTS) Primary psychotherapy intervention programs, 217 Problem-solving approach, 376 377 Problem-solving skills, 366 training, 372 373

Subject Index

Productive exposure tasks identification, 419 420 Progressive muscle relaxation, 234 235, 371 exercises, 128 129 PRT. See Psychoeducation with relaxation training (PRT) Psychoanalytic theory, 4 5 Psychoeducation, 16, 69, 119 125, 196 199, 223, 274, 307 308, 366, 413 419 components, 248 251 and developing formulation, 274 280 for exposure therapy, 39 46 with anxious youth, 40 42 challenges, 60 62 implementing exposure therapy, 48 54 providing treatment rationale, 46 48 maximizing exposure therapy outcomes, 54 60 strategies to enhance arousal and engagement, 57 58 strategies to enhance consolidation of corrective learning, 59 60 visual attention avoidance, 55 57 and treatment rationale, 369 370 Psychoeducation with relaxation training (PRT), 399 Psychological control, 327 Psychopathology in family, 324 325 Public speaking. See Glossophobia

Q Question cards, 133 135

R Randomized controlled trials (RCTs), 383, 410 411 Rapport building, 42, 196 199 RCADS. See Revised Child Anxiety and Depression Scale (RCADS) RCTs. See Randomized controlled trials (RCTs) Real-time parent coaching, 119 125 Reciprocal inhibition, 5 7 Reflection, 121t Reinforce psychoeducation principles, 199 Reinforcement, 125 126 Relapse prevention, 260 Relaxation, 366 and coping with negative affect, 370 371

453

Remote treatment for anxiety disorder, 23 24 for OCD, 28 29 Rescorla Wagner model, 10 11, 15 16 Resistance, 157 Response prevention, 246 247 Retrieval cues, 14 Review and relapse prevention, 312 Revised Child Anxiety and Depression Scale (RCADS), 169 Rewarding exposure, 100 104 Role-plays, 135 136, 205 206, 211 213, 231t, 384

S SAD. See Separation anxiety disorder (SAD); Social anxiety disorder (SAD) Safety assessments, 376 377 behaviors, 180 signals, 13 Safety-seeking behaviors (SSB), 13, 151 153 Salivary oxytocin, 328 329 SCARED. See Screen for Child Anxiety Related Emotional Disorders (SCARED) School Speech Questionnaire (SSQ), 118 119 School-related GAD worries, 224t, 225t, 226 237 Coping Cat program, 223 224, 233 235 preparing and coordinating with other individuals, 237 preparing parents/family, 235 236 preparing youth for specific exposure tasks, 233 235 Screen for Child Anxiety Related Emotional Disorders (SCARED), 75 Selective mutism (SM), 113 SM Teach session, 119 symptoms of, 116 Selective Mutism Interaction Coding System (SMICS), 118 Selective Mutism Questionnaire (SMQ), 118 119 Self-efficacy, 178 Self-harm deterioration, 138 Semi-structured diagnostic interviews, 70 71 Separation anxiety disorder (SAD), 143 145, 215 216 challenging issues, 156 159

454

Subject Index

Separation anxiety disorder (SAD) (Continued) in childhood, 144 145 clinician discomfort, 158 ethical considerations, 158 159 hierarchy for child with, 148f parental attitudes and behaviors, 157 158 treatment of, 146 147 youth factors, 150t, 154 155 youth resistance, 156 157 youth with, 144 Shaping of exposure therapy, 128 techniques, 127 Short-term exposure distress, 391 Skill building, 308 309 SM. See Selective mutism (SM) SMICS. See Selective Mutism Interaction Coding System (SMICS) Smoke alarm, 119 SMQ. See Selective Mutism Questionnaire (SMQ) Social anxiety, 196 experiences, 298 299 interactions, 116 117, 193 194, 206 207 motivation, 215 216 phobia, 71, 361 362 skills, 205 207 Social anxiety disorder (SAD), 13 14, 25 26, 193 building rapport, 196 199 case example, 196, 198 199, 201 202, 204, 206 207, 209 214 celebration, 213 214 cognitive restructuring, 202 204 constructing anxiety/avoidance hierarchy, 199 202 continued exposure practice, 211 213 first exposure practice, 207 211 goal setting, 199 202 orientation to treatment, 196 199 potential treatment challenges, 214 216 psychoeducation, 196 199 relapse prevention, 213 214 relevant therapy manuals, 217 skill review, 213 214 social skills and assertiveness training, 205 207 therapy structure, 195 196 Socratic dialogs, 116

Specific phobia, 26, 165 assessment, 166 167 behavioral assessment, 169 170 case example, 166 challenging issues, 184 186 clinical interview and additional questionnaires, 167 169 exposure treatment, 174 features of good step ladder, 175 178, 177f integration assessment results, 171 involving family, 182 184 steps toward evidence-based treatment plan, 182t tips and tricks, 183 184 maintaining improvement, 181 tips and recommendations, 178 181 treatment plan, 171 174 Spence Children’s Anxiety Scale, 169 Spun-glass theory of mind, 100, 105 Squeezing lemons activity, 128 129 SSB. See Safety-seeking behaviors (SSB) SSQ. See School Speech Questionnaire (SSQ) “Stand Up, Speak Out” program, 299 Step ladder, 53 54, 175 178, 177f STEPS framework, 372 373 Stimulus complex, 89 Stimulus fading of exposure therapy, 126 127, 130 Subjective units of distress (SUDs), 79, 90, 148 149, 170, 208, 223 224, 239, 408 Subjective units of distress scale (SUDS), 251 252, 369 370, 389 Symptom checklist, 72 73 Symptom hierarchy, 82. See also Fear hierarchy adjustments throughout treatment, 82 creativity, 80 81 establishing anchors, 79 80 evidence-based assessment to build hierarchy, 70 hierarchy, 78 79, 81 interviews and measures for practicing clinician, 70 74 translating assessment into treatment, 76 78 youth and parent report of symptom severity and impairment, 74 76 Systematic desensitization, 4 7

Subject Index

T Tangible reward systems, 126 Target stimuli identification, 88 89 Teens, 298 Telecommunication technologies, 23 24 Telehealth technology, 135 Teletherapy, 23 24 Termination, planning for, 108 Theoretical models, 194 195 Therapeutic effect, 194 195 Therapists, 122 125, 271, 277, 414, 418 factors, 105 107 role of, 283 Therapy graduation certificate, 214 manuals, 217 session, 213 structure, 195 196 therapy-interfering behaviors, 263 264 Thinking traps, 202 204 Three learning pathways, 174 Three-component model, 204 of anxiety, 199 Tokens, 153, 345 Tolerance strategies, 234 235 Traditional CBT methods, 115 116 Transdiagnostic interventions, 361 362 advantages with children and adolescents, 365 366 avoidance and withdrawal as maladaptive coping responses to stress, 363 364 case example, 369 376 current and future directions, 378 379 evidence base for internalizing adults, 363 general considerations for implementation of BBT, 376 378 increasing engagement and activation, 374 376 for internalizing problems in youth, 363 problem-solving skills training, 372 373 psychoeducation and treatment rationale, 369 370 reducing avoidance and setting goals, 373 374 relaxation and coping with negative affect, 370 371 review and relapse prevention, 376 targeting internalizing problems as cluster, 362 363 from traditional CBT for youth anxiety, 364 365

455

transdiagnostic BBT for pediatric anxiety and depression, 366 369 Transfer-of-control model of treatment, 337 Treatment outcome, 8 9, 27, 30, 70 71, 323, 327, 408, 422 Treatment plan, 168 169, 171 174 treatment options, 171 174 Treatment priorities, 377 Trial and error, 173 174 Trouble-shooting exposures with children and adolescents, 384 393 misappraisal of exposure distress, 385 390 patient resistance to completing exposures, 390 393 with clinicians, 399 402 with parents and caregivers, 393 399 difficulty implementing exposures, 395 399 difficulty understanding underlying principles, 393 395 persistent accommodation, 395 396 pushing too little or much, 397 399 unwillingness to monitor and/or perform exposures, 397 Troubleshooting, 423 425

U Unconditional stimulus (US), 4 5, 55 56 Unexpected events, 376 377 Unified Protocol for Emotional Disorders (UP), 299, 379

V Values-based approach, 250 251, 261 VDI. See Verbal-Directed Interaction (VDI) Verbal behavior, 125 Verbal Output during Interactions in Classroom Environment Coding System (VOICE), 118 Verbal-Directed Interaction (VDI), 122, 123t, 124t Verbalization goals, 136 137 Videoconferencing on smartphones, 135 Virtual reality (VR), 400 Vivo exposures, 146 147 VOICE. See Verbal Output during Interactions in Classroom Environment Coding System (VOICE) VR. See Virtual reality (VR)

456 W “White-knuckling” through exposures, 264 Wolpe’s systematic desensitization procedure, 5 7 Worry/fear thermometer, 148 149

Y Young adults, exposure with, 295 Younger children, 154 155, 277, 279 280 anxiety rating scale, 280 building hierarchy, 280 281 challenging issues, 288 290 child refusing treatment, 289 designing exposure tasks, 282 284 family dynamics, 289 290 implementing exposure, 284 288 modifications to, 273 274 parental factors, 289 290

Subject Index

psycho-education and developing formulation, 274 280 Youth, 155 exposure therapy for treating SAD in, 154 155 cultural considerations, 155 developmental level, 154 155 report of symptom severity and impairment in anxiety and OCD, 74 76 resistance, 156 157 transdiagnostic approach from traditional CBT for youth anxiety, 364 365 transdiagnostic interventions for internalizing problems, 363 youth anxiety disorders, CBT for, 22 youth OCD, CBT for, 26 27