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2013 37: 211Behav ModifJacobsen, Lisa R. Hale and Stephen P. H. Whiteside

Michelle R. Gryczkowski, Michael S. Tiede, Julie E. Dammann, Amy BrownAnxiety Disorders

The Timing of Exposure in Clinic-Based Treatment for Childhood

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Behavior Modification37(2) 211 –225

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456546 BMO37210.1177/0145445513482394Behavior ModificationGryczkowski et al.

1Mayo Clinic, Rochester, MN, USA2Kansas City Center for Anxiety Treatment, KS, USA 3University of Missouri-Kansas City, MO, USA

Corresponding Author:Stephen Whiteside, Department of Psychiatry and Psychology, Mayo Clinic, West 11, 200 First St., SW, Rochester, MN, 55905, USA. Email: [email protected]

The Timing of Exposure in Clinic-Based Treatment for Childhood Anxiety Disorders

Michelle R. Gryczkowski1, Michael S. Tiede1, Julie E. Dammann1, Amy Brown Jacobsen2,3, Lisa R. Hale2,3, and Stephen P. H. Whiteside1

Abstract

The present study examines treatment length and timing of exposure from two child anxiety disorders clinics. Data regarding symptoms and treatment charac-teristics for 28 youth were prospectively obtained through self, parent, and ther-apist report at each session. Information regarding length of treatment, timing of exposure initiation, and drop-out rates were compared with those obtained through efficacy and effectiveness trials of manualized treatment for anxious youth. Findings from the authors’ clinical data revealed significantly shorter treat-ment duration with exposures implemented sooner than in the previous studies. Dropout rates were significantly higher than in the efficacy trial but comparable with the effectiveness trial. Outcome data from a subset of eight patients revealed large effect sizes. These findings suggest that effective treatment can be shorter and more focused on exposure than is often outlined in manuals and have important implications for outcome research and dissemination.

Keywords

external validity, evidence-based practice, exposures, children, anxiety, cognitive-behavioral therapy

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212 Behavior Modification 37(2)

According to epidemiological data, anxiety disorders are among the most common childhood mental health diagnoses (Merikangas & Avenevoli, 2002) with lifetime prevalence rates ranging from 6% to 15% (Silverman & Ginsburg, 1998; U.S. Public Health Service, 2000). Anxiety disorders cause substantial impairment across a variety of domains of functioning (e.g., academic, social, familial); are highly comorbid with other anxiety, emo-tional, and behavioral disorders; and often persist into adulthood (Anderson, 1994; Chorpita & Southam-Gerow, 2006; Mendlowicz & Stein, 2000; Quilty, Van Ameringen, Mancini, Oakman, & Farvolden, 2003). Cognitive-behavioral therapy (CBT) is an efficacious treatment for childhood anxiety disorders (Compton et al., 2010); however, the need for increased focus on external validity through effectiveness studies has recently been empha-sized, particularly given meta-analytic findings that treatments deemed efficacious may not hold up in effectiveness trials (Chorpita et al., 2011; Weisz, Donenberg, Han, & Weiss, 1995; Weisz & Jensen, 2001). Such find-ings (or lack thereof) call into question the transportability of manualized treatment to clinical practice.

The treatment manual most widely used in randomized controlled trials (RCTs) of childhood anxiety treatment is the Coping Cat (CC; Kendall, 2000). This empirically supported treatment is currently the gold standard protocol for treating anxious youth. It prescribes 16 to 20 sessions, the first half of which focuses on psychoeducation, emotional awareness, relaxation, and cognitive restructuring, whereas the latter half focuses on facing fears through exposures. In a recent RCT conducted by Walkup and colleagues (2008) comparing CBT, sertraline, and their combination to a pill placebo, a condensed 12-session version of CC was found to be superior to placebo but less effective than combined treatment. However, in two recent effective-ness studies (Barrington, Prior, Richardson, & Allen, 2005; Southam-Gerow et al., 2010), CC failed to demonstrate superiority over usual care with respect to percentage of youth no longer meeting criteria for an anxiety dis-order. Southam-Gerow and colleagues commented on the fact that only 54.2% of the youth in the CBT condition received the full 16 sessions and only 58% received exposure therapy, which is thought to be central to anxi-ety disorder treatment (Chorpita & Southam-Gerow, 2006; Davis & Ollendick, 2005; Kendall et al., 2005; Silverman & Kurtines, 1996). Thus, it is possible that the CBT group would have demonstrated greater effects had more of the youth received exposure or a larger dose of it.

In contrast to CC, other researchers have emphasized the use of exposure earlier in treatment and de-emphasized the use of other anxiety management techniques. For example, a multiple baseline study provides initial support




Gryczkowski et al. 213

for the efficacy of a modular approach that reviews psychoeducation and constructs a fear hierarchy before initiating exposures (Chorpita, 2007; Chorpita, Taylor, Francis, Moffitt, & Austin, 2004). A retrospective examina-tion of outpatient treatment of child anxiety disorders consistent with the modularized approach found that when exposures were initiated by approxi-mately the third session, large treatment effect sizes could be obtained in roughly half the sessions of CC (Vande Voort, Svecova, Brown Jacobsen, & Whiteside, 2010). Moreover, they found that the more time the clinician dedi-cated to anxiety management strategies such as cognitive techniques, the less time was spent on exposures. This finding was particularly important, as the number of exposures correlated positively with improvements in functioning, whereas the use of other anxiety management techniques correlated nega-tively with this outcome. The authors concluded that a shorter and more flex-ible treatment approach than what is prescribed in manuals for anxiety disorders can be effective for at least some children.

Although Vande Voort and colleagues (2010) demonstrated that it is pos-sible to effect improvement with shorter, more exposure-focused treatment, the degree to which these patients are representative of children with anxiety disorders is unknown because the sample was restricted to treatment com-pleters. Specifically, it is possible that the patients in the study were atypi-cally receptive to exposures and that many other patients dropped out of treatment because they either found it unacceptable or did not respond effec-tively and were subsequently excluded from the sample. The current study was designed to build on the previous findings by prospectively examining the course of clinic-based treatment for childhood anxiety disorders. This methodology allowed for examination of treatment adherence, more accu-rate documentation of treatment components, and collection of symptom data throughout the intervention. We hypothesized that (a) treatment will, on average, consist of fewer sessions and implement exposure earlier than rec-ommended in treatment manuals, (b) a greater percentage of patients will receive exposure therapy than has been achieved in effectiveness trials of manualized treatment, and (c) dropout rates will be similar to those in effec-tiveness trials.

MethodParticipants

Data regarding 28 consecutive child patients (17 male, 60.7%) ranging in age from 6 to 18 years (M = 10.89, SD = 3.53) seen in two outpatient clinics for





an anxiety disorder were collected under an Institutional Review Board (IRB)-approved protocol. The majority of children were Caucasian (82.1%; 3.6% African American, 14.3% unidentified). Parents were predominately married and had some postsecondary education. A doctoral level clinical psychologist, supervised master’s level clinician, or child psychiatrist made diagnoses after an evaluation as part of regular clinical practice. Diagnoses were determined for all patients consistent with the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). The majority of the patients had a primary anxiety disorder (27, 96.4%), although many had multiple diagnoses (14, 40%). The most common anxiety diagnosis was obsessive-compulsive disorder (OCD; 25%), followed by separation and generalized anxiety disorders (17.9% each).

TreatmentTreatment was provided by one of five therapists within the two programs: three licensed doctoral level clinical psychologists specializing in the treat-ment of childhood anxiety disorders and two master’s level therapists super-vised by one of the psychologists. All therapists had detailed knowledge of and experience using treatment manuals (i.e., Chorpita, 2007; Kendall, 2000) and provided CBT, including exposures. The treatment approach was consis-tent with Chorpita’s modularized approach.

Data CollectionAs part of the standard assessment procedure in the anxiety disorders clin-ics, all children and their parent(s) completed a variety of questionnaires, including a demographic form and standardized measures assessing anxiety symptom severity, functional impairment, and various additional measures not used in the present study. Beginning at the first treatment session fol-lowing the assessment, the child, a parent, and the therapist completed a data entry form. All patients with a primary anxiety disorder were eligible; one family did not allow data to be used for research purposes and was excluded. The child and a parent completed a questionnaire at the beginning of each session that included idiographic questions about symptom severity and impairment. At the end of each session, the therapist recorded the treat-ment techniques (e.g., relaxation, cognitive restructuring, exposure) that had been implemented during the session. The reliability of clinician ratings for





implementation of exposure was examined for 25% of patients by a trained assistant through a retrospective chart review using the procedure from a previous study (Vande Voort et al., 2010). The agreement level between the rater and the therapist was 84.8%, demonstrating good reliability.

Data collection continued until the treatment of the presenting anxiety complaint was completed or the patient dropped out of therapy. Information regarding the final disposition was gathered through a chart review with a patient considered a “dropout” if the last session attended did not include a discussion of having met treatment goals and agreement among the clinician, child, and parent(s) that further treatment was not necessary. Additional ses-sions for other presenting complaints (i.e., adjustment issues) or booster ses-sions were not included in the present analyses.

MeasuresSpence Children’s Anxiety Scale (SCAS). The SCAS (Spence, 1998) is a Likert-

type measure ranging from 0 (never) to 3 (always) of anxiety symptoms completed by the child (45 items) or parent (SCAS-P, 38 items; Nauta et al., 2004). Although the SCAS-P has six basic scales, only the total score was included in the present study. High internal consistency and validity data have been demonstrated for the SCAS, including group differences between clinical versus nonclinical samples, convergent validity with other anxiety measures, and discriminant validity with measures of depres-sion (Muris, Merckelbach, Ollendick, King, & Bogie, 2002; Muris, Schmidt, & Merckelbach, 2000; Spence, 1998). Similar support demonstrating internal consistency, parent–child agreement, as well as convergent and discrimi-nant validity also exists for the SCAS-P (Nauta et al., 2004). The internal consistency in the current sample for the SCAS and SCAS-P were .87 and .91, respectively.

Child Sheehan Disability Scale (CSDS). The CSDS (Whiteside, 2009) mea-sures the extent to which a child’s anxiety symptoms interfere with daily functioning. The CSDS is an adaptation of the Sheehan Disability Scale (SDS; Sheehan, 1986) and consists of items inquiring about the degree to which the child’s anxiety symptoms interfere with school, social, and family functioning. As on the SDS, items are measured on an 11-point Likert-type scale ranging from 0 (not at all) to 10 (very, very much). A 5-item parent ver-sion (CSDS-P) assesses the degree to which the parent perceives the child’s anxiety symptoms to be interfering with the child’s, as well as the parent’s, school/work, social, and family functioning.





Idiographic Anxiety Questionnaire

The child and a parent provided ratings of anxiety severity and impairment at each session. At the initial appointment, the therapist worked with the child and parent to identify the child’s primary anxiety symptom. The child and parent then rated the severity of that symptom and the degree to which that symptom interfered with functioning on an 11-point Likert-type scale ranging from 0 (not at all) to 10 (extremely). At each subsequent session, the parent and child rated the severity of the child’s anxiety symptoms and asso-ciated impairment since the last visit.

AnalysesThe characteristics of treatment were benchmarked against two studies that represent state of the art research on the gold standard manualized treatment, CC, in terms of efficacy (Child/Adolescent Anxiety Multimodal Study; CAMS; Compton et al., 2010; Walkup et al., 2008) and effectiveness (ES; Southam-Gerow et al., 2010). Single-sample t-tests were used to compare the number of sessions, the session in which exposure exercises were begun, and rate of attrition in the current sample with the previous studies. To examine treatment outcome, paired-samples t-tests were used to compare symptom and interference ratings at the first session with those gathered at the final session within a subsample of patients with complete data.

ResultsBaseline Data

At baseline, the intent-to-treat (ITT) sample of children had mean anxiety severity levels in the moderate range, as measured by the SCAS parent (M = 31.09, SD = 12.58) and child (M = 33.39, SD = 12.41) reports. Functional impairment scores, as measured by the CSDS, were similar to previously reported clinical scores (Whiteside, 2009; M = 12.33, SD = 7.50 for child report; M = 19.43, SD = 12.62 for parent report).

Treatment DescriptionsThe length of treatment for anxiety disorders ranged from 1 to 32 sessions with an average of 7.89 (SD = 5.9) sessions, which is significantly less than the 12-session protocol in the CAMS, t(27) = −3.71, p = .001, and the





14-session mean treatment length in the ES, t(27) = −5.52, p < .001. The median and modal number of sessions was 6, and 53.4% of patients attended 6 or fewer sessions. Information regarding the session in which exposures were first implemented was available for 25 patients. All received exposure therapy—significantly more than the 58% who received exposure therapy in the ES, binomial test (24), p < .001. In addition, the mean session number in which exposures began in the clinic, 1.92 (SD = .91), was significantly sooner than in the CAMS study (Session 7), t(24) = −27.94, p < .001, with all patients beginning exposures by the fourth session.

Given that exposures are typically prescribed earlier in manuals for OCD than other anxiety disorders, the session in which exposure was initiated was examined separately for patients with (n = 7) and without OCD (n = 18). The mean session in which exposure was initiated did not differ between the OCD (2.29; SD = 1.11) and non-OCD (1.78; SD = 0.81) patients, t(23) = 1.27, p = .217.

Treatment DropoutsOf the initial 28 patients, 16 (57.1%) successfully completed treatment based on chart review. This completion rate is significantly lower than the 95.7% in the CAMS study, binomial test (27), p < .001, and not significantly differ-ent from the rate of 54.2% receiving the full 16 sessions in the ES, binomial test (27), p = .453.

Treatment OutcomeOutcome analyses were completed with the eight patients for whom com-plete session-by-session data were available. Figure 1 presents mean child- and parent-reported idiographic anxiety and interference ratings at each session. The effectiveness of treatment was analyzed through paired-sample t-tests comparing pre- and post-treatment idiographic anxiety and interfer-ence ratings. Significant pre–post reductions were found for parent-reported anxiety ratings (pre = 6.88 [2.64], post = 2.75 [1.49]), t(7) = 3.78, p = .007, and interference ratings (pre = 5.75 [3.33], post = 1.75 [1.04]), t(7) = 3.23, p = .014, and for child-reported anxiety ratings (pre = 6.25 [4.13], post = 2.00 [2.27]), t(7) = 3.19, p = .015. The reduction in mean child-reported idio-graphic interference ratings was not significant (pre = 4.13 [3.87], post = 1.63 [1.69]), t(7) = 1.93, p = .095. Consistent with the CAMS, effect sizes were computed using Hedges’s g, which is bias corrected and more appropri-ate for small sample sizes (Grissom & Kim, 2005). These effect sizes, as well





as the effect sizes found in previous RCTs, are presented in Table 1. Cohen (1977) suggested that effect size magnitudes of 0.20, 0.50, and 0.80 corre-spond to small, medium, and large effects, respectively.

DiscussionThis study compared exposure-focused treatment with efficacy and effec-tiveness trials of manualized intervention for childhood anxiety disorders (Southam-Gerow et al., 2010; Walkup et al., 2008). Similar to a previous examination (Vande Voort et al., 2010), we found that treatment introducing exposures earlier and consisting of fewer sessions than CC was effective in reducing anxiety symptoms and associated impairment. Moreover, although attrition was substantially greater than that found in a well-controlled effi-cacy trial, it was similar to rates in an effectiveness study. In addition, sig-nificantly more patients received at least an introduction to exposure therapy in the current sample compared with clinic-based CC. Therefore, introducing exposures early in treatment does not necessarily lead to higher attrition and

Figure 1. Graph of mean idiographic anxiety and interference ratings at each session.





has the potential to improve clinic outcomes by increasing the number of patients introduced to exposure.

The current results raise the possibility that exposure exercises can be introduced into treatment earlier than what is prescribed in the most heavily researched treatment manual. Although most protocols include the use of exposure, this technique is often instituted after multiple sessions spent intro-ducing alternative anxiety coping strategies (e.g., relaxation, cognitive restruc-turing). The inclusion of these strategies is designed to directly reduce symptoms, increase engagement in treatment, and facilitate maintenance of gains. In contrast, there is some evidence to suggest that breathing retraining, relaxation, and cognitive coping are either unnecessary or related to poorer outcomes (Craske & Barlow, 2008; Deacon & Abramowitz, 2004; Vande Voort et al., 2010). The similar levels of attrition and the large treatment effect sizes associated with exposure-focused treatment relative to CC administered in a clinical setting do not support the assumption that additional anxiety cop-ing strategies must precede the introduction of exposure exercises. As such, these findings highlight the need for dismantling studies to determine the extent to which nonexposure anxiety management techniques are necessary.

Determining the appropriate combination of treatment components and order in which they are implemented has important implications for improv-ing interventions for children with anxiety disorders. To begin with, exposure exercises are thought to be a key component in the treatment of anxiety dis-orders and may be the primary mechanism of change (Beidel, Turner, & Morris, 2000; Davis & Ollendick, 2005; Kendall et al., 2005; Salcioglu,

Table 1. Treatment Effect Sizes (Hedges’s g) Across Studies.

Present study CAMSEffectiveness

RCTCoping Cat

original

Source Anxiety Interference PARS CGI STAIC-T STAIC-T

Parent 1.82 1.24 — — 0.44 0.73Self 1.41 0.79 — — –0.27 1.47Clinician — — — 1.61 — —Combined — — 1.62 — — —

Note: CAMS = Child/Adolescent Anxiety Multimodal Study; RCT = randomized controlled trial; PARS = Pediatric Anxiety Rating Scale. CGI = Clinical Global Impression–Severity scale. STAIC-T = State-Trait Anxiety Inventory for Children–Trait Version. In present study, effect sizes are calculated from mean differences in idiographic anxiety severity and interference measures. Combined scores = self + parent report.





Basoglu, & Livanou, 2007; Silverman & Kurtines, 1996). The fact that more than half of the patients in the current study and the comparison effectiveness trial (Southam-Gerow et al., 2010) discontinued treatment before the session in which exposures are recommended to begin in CC suggests that many children will not receive the most important treatment component even if they receive treatment consistent with the most recent research. Alternatively, although it may not be essential to begin with nonexposure techniques, they may increase acceptability of exposures among patients who are treatment resistant or provide patients with more skills to handle future anxiety prob-lems. To be sure, more research is needed to clarify the role of such techniques.

The current findings may also have implications for improving the dis-semination of effective treatments. The fact that few clinicians who describe their therapeutic orientation as cognitive behavioral actually use exposure regularly when treating anxiety disorders is concerning (Freiheit, Vye, Swan, & Cady, 2004; Goisman et al., 1993; Valderhaug, Gotestam, & Larsson, 2004). Lack of knowledge, lack of adequate training in exposure therapy, fear of patient dropout, ease of administration of alternative techniques, and clini-cian discomfort with inducing anxiety in their patients are all potential expla-nations for why exposure is infrequently being implemented. Thus, more education and a greater emphasis on exposures in treatment manuals are nec-essary. As previously discussed by Vande Voort and colleagues (2010), the low rate of empirically based treatment in clinical practice should not be solely attributed to therapist factors as there appears to be some merit to clini-cian concerns that manualized treatments are too long and inflexible (Addis, 2002). These views are further supported by the fact that many patients may achieve significant symptom relief in 6 to 10 sessions without receiving all prescribed treatment components. An approach that begins with exposures and has the flexibility to add additional techniques as needed (e.g., Chorpita, 2007) may not only be more acceptable to clinicians, it may also be more effective and cost-efficient in clinical settings.

The present study is not without its limitations. To begin with, the current study was based on a small sample size and needs to be replicated in a larger, more diverse sample. Second, the diagnoses were not based on a structured interview, which raises the possibility that the current sample differed from the previous trials in important ways, such as in symptom severity. However, the intention of this line of research is to inform the development of evidence-based treatment from a clinical perspective. As such, the current sample likely bears a close resemblance to patients seen by practitioners in outpatient clinics who are the targets of dissemination. Third, because the current study





was descriptive and lacked a comparison group, it is not possible to weigh the relative merits of different approaches to treatment. However, the current design is sufficient to support the appropriateness of an exposure-focused condition in dismantling studies.

Despite these limitations, the current study suggests that treatment manu-als focusing more directly on exposure have the potential to maintain efficacy without decreasing acceptability and effectiveness. Perhaps one of the most pressing issues facing the field of child anxiety disorders is the determination of essential and nonessential treatment components (Kazdin & Nock, 2003). The development of more effective and cost-efficient treatments has the potential to improve efforts toward dissemination and reduce the gap between effect sizes found in effectiveness and efficacy trials (Barrington et al., 2005; Chorpita et al., 2011; Southam-Gerow et al., 2010; Weisz et al., 1995).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publica-tion of this article.

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Author Biographies

Michelle R. Gryczkowski is a postdoctoral fellow in Child Clinical Psychology at Mayo Clinic in Rochester, MN and specializes in child anxiety disorders. Her research interests include treatment of childhood anxiety disorders and parenting in relation to child anxiety and externalizing disorders.

Michael S. Tiede is a Master’s level psychologist at Mayo Clinic in Rochester, MN. He is the coordinator of the Pediatric Anxiety Disorder Clinic and provides a variety of mental health services to children, adolescents, and their families.

Julie E. Dammann is a Master’s level psychologist at Mayo Clinic in Rochester, MN. She is a clinician in the Pediatric Anxiety Disorder Clinic and provides a variety of mental health services to children, adolescents, and their families.

Amy Brown Jacobsen is a CBT/ERP Specialist at Kansas City Center for Anxiety Treatment and an Adjunct Associate Professor in the Department of Psychology at the University of Missouri-Kansas City. Her research interests include the role of the family environment in anxiety disorders and the development of intervention pro-grams for children and families affected by anxiety.





Lisa R. Hale is the founder and director of Kansas City Center for Anxiety Treatment and an Adjunct Associate Professor in the Department of Psychology at the University of Missouri-Kansas City. She is a strong advocate for education surrounding evi-dence-based treatment and increasing access to quality care. Her research interests include the identification of cognitive risk factors for anxiety disorders and issues of treatment dissemination and adherence across neuropsychiatric and behavioral health conditions.

Stephen P. H. Whiteside is an Associate Professor of Psychology and director of the Pediatric Anxiety Disorder Clinic at Mayo Clinic in Rochester, MN. His research interests include the assessment and treatment of child and adolescent on anxiety disorders. Previous and ongoing projects include using neuroimaging to evaluate the effectiveness of psychological treatments for OCD, developing assessment proce-dures for anxiety, and developing intensive treatments for OCD and other anxiety disorders.

Publisher’s Note:

This article was inadvertently published in Behavior Modification 37(1), 113-127.Same article has been reprinted as part of this special issue.




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