Emily M. Becker-Haimes
Juventino Hernandez Rodriguez
Courtney Benjamin Wolk- 1Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- 2Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, PA, United States
- 3Department of Psychological Science, University of Texas Rio Grande Valley, Edinburg, TX, United States
Editorial on the Research Topic
Implementation of evidence-based treatments for child anxiety and related disorders across diverse contexts
Youth anxiety and related disorders, such as obsessive-compulsive disorder and post-traumatic stress disorder, are prevalent (1), and on the rise (2). Ensuring that anxious youth receive timely and evidence-based treatment is critical; left untreated, these disorders are predictive of a host of future negative outcomes including continued or worsening anxiety, depression, substance abuse, and suicide (3–8). Unfortunately, it can take 15 years or more after a problem is recognized for someone with an anxiety or related disorder to connect with evidence-based psychosocial care, and most youth with anxiety who seek treatment will not receive effective care. This is in large part because as many as 90% of practicing mental health clinicians do not routinely deliver exposure-based cognitive behavioral therapy (Ex-CBT) to their clients struggling with anxiety (9–12), which is the gold-standard, first-line, evidence-based practice (EBP) for anxiety and related disorders (13). In other words, Ex-CBT demonstrates a major research to practice gap: while Ex-CBT is one of the treatments for which we have perhaps some of the strongest evidence for its efficacy and effectiveness, it remains one of the least used treatments within routine clinical care. Note we use the term Ex-CBT to refer to any CBT-based protocol that recognizes maladaptive anxious avoidance as a hallmark psychopathological characteristic of an anxiety or related disorder and works to minimize avoidance and safety-seeking behaviors through approach-oriented strategies (e.g., in vivo exposures, interoceptive exposure, exposure with response prevention, and prolonged exposure/trauma narratives).
Using insights from implementation science, or the scientific study of how to increase the use of EBPs in routine clinical settings to improve care quality (14), the past few decades have seen advances in efforts to understand the major barriers leading to the underutilization of Ex-CBT. Identified barriers range from concerns about the complex nature of the intervention itself (15) and poor marketing of Ex-CBT to practicing clinicians and families (16), negative beliefs and misconceptions about Ex-CBT held by clinicians (17–20), organizational constraints and intervention delivery challenges (21, 22), and systemic barriers related to factors such as reimbursement rates and limited funding for specialized training (23). These implementation barriers also occur alongside historical underrepresentation of marginalized and minoritized individuals in clinical treatment trials and limited attention to ways of culturally tailoring treatments to increase engagement and effectiveness. Despite increased understanding of why Ex-CBT remains so underutilized, efforts to increase Ex-CBT delivery have had only limited or mixed success (10, 24, 25) or remain in early stages of pilot testing (26, 27). This Research Topic is intended to further advance understanding of how to improve implementation of Ex-CBT for pediatric anxiety and related disorders across the diverse contexts in which youth may receive care, such as outpatient mental health, primary care, and schools.
The varied topics published in this special Research Topic highlight the many ways that researchers are attempting to address the challenge of how to ensure youth with anxiety and related disorders receive the highest quality treatment service. Several articles in this series focus specifically on the need to adapt existing models of Ex-CBT to better fit non-specialty contexts as well as better align the content and format of treatment to address the needs of youth who historically have not been well-represented in clinical trials (e.g., those of historically minoritized identities, those with complex comorbidities). For example, Kendall et al. describe how the various ways a single Ex-CBT protocol—the Coping Cat program (28)—can be adapted in a myriad of ways to improve implementation fit across clinical settings. In contrast, Herres et al. posit that Ex-CBT protocols likely need to be integrated with other treatments drawn from family systems protocols to truly address the complex symptom presentation that many youth present with in community settings. Building on work by others suggesting we should be co-developing novel protocols in tandem with local context leaders to enhance implementabilty and scalability of treatments (29), rather than relying on extant protocols, Gellatly et al. describe the complexity of this process, underscoring the need to collaborate with local context leaders and the critical importance of cultural and contextual considerations to support successful protocol design. Underscoring the importance of treatment adaptation research is work led by Lawson et al. empirically demonstrating the cost-effectiveness of a culturally adapted version of school-based Ex-CBT relative to an unadapted Ex-CBT model.
In an alternative approach, Frank et al. highlight the importance of speaking with caregivers of anxious youth to understand the family experience of trying to access Ex-CBT. Their work suggested several promising implementation strategies targeted directly to consumers that could expedite families' access to quality services. Remaining studies in this Research Topic focused directly on how to best support clinicians to deliver Ex-CBT with fidelity to optimize outcomes. Meza et al. highlight specific supervisory strategies that are associated with improved clinician delivery of exposure-based techniques for youth experiencing symptoms of post-traumatic stress, while Kemp et al. discuss the potential of a novel experiential training strategy (“exposure to exposure”) to directly address the negative beliefs many clinicians hold about Ex-CBT.
Taken together, this Research Topic highlights the importance of adapting Ex-CBT protocols to improve their cultural responsiveness and implementation fit, the critical importance of including patient and family voices in designing implementation strategies to improve Ex-CBT uptake, and the continued need for testing novel strategies that directly address known barriers to Ex-CBT implementation. At the same time, this Research Topic highlights the extraordinary amount of remaining work to be done to truly increase the accessibility and effectiveness of Ex-CBT to all youth who could benefit. In particular, the field will benefit from increasing clarity on how to optimize the cultural responsiveness of Ex-CBT and how and when to sequence Ex-CBT with other treatment models to optimize innovation fit to the increasingly varied settings in which youth seek treatment. This Research Topic also highlighted several promising implementation strategies (e.g., targeted supervisory support, exposure to exposure) ripe for testing in confirmatory hybrid effectiveness-implementation trials. Given the current children's mental health crisis (30), we urge a continued focus on research in this area to alleviate the distress and burden experienced by anxious youth and their families.
Author contributions
EB-H drafted the initial version. JH and CW provided input and revision to manuscript content. All authors contributed to the conceptualization of content for this manuscript.
Acknowledgments
The authors gratefully acknowledge Ms. Annalisa Fang for her support in preparing this manuscript for publication.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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References
1. Merikangas KR, He J-P, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. (2010) 49:980–9. doi: 10.1016/j.jaac.2010.05.017
2. Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA Pediatr. (2021) 175:1142–50. doi: 10.1001/jamapediatrics.2021.2482
3. Barzilay R, Moore TM, Greenberg DM, DiDomenico GE, Brown LA, White LK, et al. Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry. (2020) 10:291. doi: 10.1038/s41398-020-00982-4
4. James SC, Farrell LJ, Zimmer-Gembeck MJ. Description and prevalence of OCD in children and adolescents. Wiley Handb Obsess Comp Disor. (2017) 1:5–23. doi: 10.1002/9781118890233.ch1
5. Bentley KH, Franklin JC, Ribeiro JD, Kleiman EM, Fox KR, Nock MK. Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review. Clin Psychol Rev. (2016) 43:30–46. doi: 10.1016/j.cpr.2015.11.008
6. Doering S, Lichtenstein P, Gillberg C, Middeldorp CM, Bartels M, Kuja-Halkola R, et al. Anxiety at age 15 predicts psychiatric diagnoses and suicidal ideation in late adolescence and young adulthood: Results from two longitudinal studies. BMC Psychiatry. (2019) 19:363. doi: 10.1186/s12888-019-2349-3
7. Benjamin CL, Harrison JP, Settipani CA, Brodman DM, Kendall PC. Anxiety and related outcomes in young adults 7 to 19 years after receiving treatment for child anxiety. J Consult Clin Psychol. (2013) 81:865–76. doi: 10.1037/a0033048
8. Wolk CB, Kendall PC, Beidas RS. Cognitive-Behavioral Therapy for Child Anxiety Confers Long-Term Protection From Suicidality. J Am Acad Child Adolesc Psychiatry. (2015) 54:175–9. doi: 10.1016/j.jaac.2014.12.004
9. Becker-Haimes EM, Okamura KH, Wolk CB, Rubin R, Evans AC, Beidas RS. Predictors of clinician use of exposure therapy in community mental health settings. J Anxiety Disord. (2017) 49:88–94. doi: 10.1016/j.janxdis.2017.04.002
10. Chu BC, Crocco ST, Arnold CC, Brown R, Southam-Gerow MA, Weisz JR. Sustained implementation of cognitive-behavioral therapy for youth anxiety and depression: long-term effects of structured training and consultation on therapist practice in the field. Prof Psychol Res Pr. (2015) 46:70–9. doi: 10.1037/a0038000
11. Hipol LJ, Deacon BJ. Dissemination of evidence-based practices for anxiety disorders in Wyoming: A survey of practicing psychotherapists. Behav Modif. (2013) 37:170–88. doi: 10.1177/0145445512458794
12. Whiteside SPH, Sattler A, Ale CM, Young B, Hillson Jensen A, Gregg MS, et al. The use of exposure therapy for child anxiety disorders in a medical center. Professional Psychol. (2016) 47:206–14. doi: 10.1037/pro0000077
13. Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence base update: 50 years of research on treatment for child and adolescent anxiety. J Clin Child Adoles Psychol. (2016) 45:91–113. doi: 10.1080/15374416.2015.1046177
14. Eccles MP, Mittman BS. Welcome to Implementation Science. Implement Sci. (2006) 1:1. doi: 10.1186/1748-5908-1-1
15. Becker-Haimes EM, Klein CC, Frank HE, Oquendo MA, Jager-Hyman S, Brown GK, et al. Clinician maladaptive anxious avoidance in the context of implementation of evidence-based interventions: a commentary. Front Health Serv. (2022) 2:833214. doi: 10.3389/frhs.2022.833214
16. Becker-Haimes EM, Stewart RE, Frank HE. It's all in the name: Why exposure therapy could benefit from a new one. Curr Psychol. (2022) 2:1–7. doi: 10.1007/s12144-022-03286-6
17. Deacon BJ, Farrell NR, Kemp JJ, Dixon LJ, Sy JT, Zhang AR, et al. Assessing therapist reservations about exposure therapy for anxiety disorders: the therapist beliefs about exposure scale. J Anxiety Disord. (2013) 27:772–80. doi: 10.1016/j.janxdis.2013.04.006
18. Meyer JM, Farrell NR, Kemp JJ, Blakey SM, Deacon BJ. Why do clinicians exclude anxious clients from exposure therapy? Behav Res Ther. (2014) 54:49–53. doi: 10.1016/j.brat.2014.01.004
19. Pittig A, Kotter R, Hoyer J. The struggle of behavioral therapists with exposure: self-reported practicability, negative beliefs, and therapist distress about exposure-based interventions. Behav Ther. (2019) 50:353–66. doi: 10.1016/j.beth.2018.07.003
20. Becker CB, Zayfert C, Anderson E, A. survey of psychologists' attitudes towards and utilization of exposure therapy for PTSD. Behav Res Ther. (2004) 42:277–92. doi: 10.1016/S0005-7967(03)00138-4
21. Ringle VA, Read KL, Edmunds JM, Brodman DM, Kendall PC, Barg F, et al. Barriers to and facilitators in the implementation of cognitive-behavioral therapy for youth anxiety in the community. Psychiatr Serv. (2015) 66:938–45. doi: 10.1176/appi.ps.201400134
22. Becker-Haimes EM, Byeon YV, Frank HE, Williams NJ, Kratz HE, Beidas RS. Identifying the organizational innovation-specific capacity needed for exposure therapy. Depress Anxiety. (2020) 37:1007–16. doi: 10.1002/da.23035
23. Wolitzky-Taylor K, Fenwick K, Lengnick-Hall R, Grossman J, Bearman SK, Arch J, et al. A preliminary exploration of the barriers to delivering (and receiving) exposure-based cognitive behavioral therapy for anxiety disorders in adult community mental health settings. Commun Ment Health J. (2018) 54:899. doi: 10.1007/s10597-018-0252-x
24. Harned MS, Dimeff LA, Woodcock EA, Contreras I. Predicting adoption of exposure therapy in a randomized controlled dissemination trial. J Anxiety Disord. (2013) 27:754–62. doi: 10.1016/j.janxdis.2013.02.006
25. Whiteside SPH, Biggs BK, Ollendick TH, Dammann JE, Tiede MS, Hofschulte DR, et al. Using technology to promote therapist use of exposure therapy for childhood anxiety disorders: a randomized pilot study. Behav Ther. (2022) 53:642–55. doi: 10.1016/j.beth.2022.01.010
26. Frank HE, Becker-Haimes EM, Rifkin LS, Norris LA, Ollendick TH, Olino TM, et al. Training with tarantulas: A randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training. J Anxiety Disord. (2020) 76:102308. doi: 10.1016/j.janxdis.2020.102308
27. Benito KG, Herren J, Freeman JB, Garcia AM, Block P, Cantor E, et al. Improving delivery behaviors during exposure for pediatric OCD: a multiple baseline training trial with community therapists. Behav Ther. (2021) 52:806–20. doi: 10.1016/j.beth.2020.10.003
29. Chorpita BF, Daleiden EL, Malik K, Gellatly R, Boustani MM, Michelson D, et al. Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India. Behav Res Ther. (2020) 133:103698. doi: 10.1016/j.brat.2020.103698
30. AAP-AACAP-CHA Declaration of a National Emergency in Child Adolescent Mental Health. (n.d.). Available online at: https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/ (accessed June 27, 2023).
Keywords: youth mental health services, implementation, evidence-based intervention, exposure therapy, anxiety
Citation: Becker-Haimes EM, Hernandez Rodriguez J and Wolk CB (2023) Editorial: Implementation of evidence-based treatments for child anxiety and related disorders across diverse contexts. Front. Psychiatry 14:1248996. doi: 10.3389/fpsyt.2023.1248996
Received: 28 June 2023; Accepted: 28 June 2023;
Published: 12 July 2023.
Edited and reviewed by: Marco Grados, Johns Hopkins University, United States
Copyright © 2023 Becker-Haimes, Hernandez Rodriguez and Wolk. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Emily M. Becker-Haimes, Emily.haimes@pennmedicine.upenn.edu
†ORCID: Emily M. Becker-Haimes orcid.org/0000-0002-9922-8667
Juventino Hernandez Rodriguez orcid.org/0000-0003-2311-4687
Courtney Benjamin Wolk orcid.org/0000-0001-9542-2801