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Background Trauma narratives are a critical, exposure-based component of trauma-focused cognitive-behavioral therapy, yet community therapists rarely use them. Given evidence that intentions to deliver elements of cognitive behavioral therapy vary by component, and that intentions to deliver exposure are the weakest, this study focused specifically on trauma narratives. We drew on a social psychology causal theory (Theory of Planned Behavior (TPB)) and an implementation science framework (the Consolidated Framework for Implementation Research (CFIR)) to glean insight into multilevel influences on trauma narrative use. While the CFIR offers a broad list of factors potentially affecting implementation, the TPB offers causal pathways between individual-level constructs that predict behavior, including the uptake of an evidence-based intervention. The integration of these approaches may provide a more complete understanding of factors affecting therapists’ use of TNs. Methods Therapists (n=65) trained in trauma-focused cognitive behavioral therapy completed a survey about their use of and beliefs about trauma narratives. Content analysis was used to identify common beliefs about trauma narratives. A subset of participants (n=17) completed follow-up qualitative interviews, which were analyzed using an integrated approach informed by the CFIR. Results While most participants reported high intentions to use TNs, nearly half reported that they did not use TNs in the last 6 months. Survey data indicate a number of TPB-related determinants related to using trauma narratives. Qualitative interviews identified CFIR-relevant contextual factors that may influence constructs central to TPB. Conclusions These results highlight the importance of integrating approaches that address multiple theoretical determinants of therapist behavior, including therapist, organizational, and client factors with causal explanations to explain implementation behavior.

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and post-treatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher ‘total dose’ of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

BackgroundEvidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research.MethodsQualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy.ResultsResponses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice.ConclusionsUsing the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.

Although schools are one of the largest providers of behavioral health services for youth, many barriers exist to the implementation of evidence-based interventions in schools. This study used the Stages of Implementation Completion (SIC) to examine school-based implementation outcomes for a computer-assisted cognitive behavioral therapy intervention for anxious youth. Organizational factors and predictors of program startup also were examined. Results indicated that the SIC detected implementation variability in schools and suggested that spending more time completing pre-implementation activities may better prepare schools for active implementation of program delivery. Furthermore, proficiency emerged as a potentially important organizational factor to examine in future school-based implementation research.

Objective This article examined associations between change in youth and family characteristics during youth anxiety treatment and long-term anxiety severity and overall functioning. Method Participants (N = 488; age 7-17 years; 45% male; 82% white) were randomized to 12 weeks of cognitive behavioral therapy (Coping Cat), medication (sertraline), their combination, or pill placebo in the Child/Adolescent Anxiety Multimodal Study (CAMS). A subset participated in the naturalistic follow-up Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS; n = 319; 3.70-11.83 years post-treatment). The current secondary analyses examined how change in anxiety severity (Child Global Impression-Severity), overall functioning (Children's Global Assessment Scale), caregiver psychopathology (Brief Symptom Inventory), caregiver strain (Family Burden Assessment Scale), and family dysfunction (Brief Family Assessment Measure) during CAMS was associated with anxiety severity and overall functioning years later (M = 7.72 years). CAMS procedures were registered on clinialtrials.gov. Results Improvements in factors related to functioning (i.e., overall functioning, family dysfunction, caregiver strain) were associated with improvements in anxiety severity in CAMELS (|βys| ≥ .04, ps ≤ .04). Improvements in factors related to psychopathology (i.e., anxiety severity, caregiver psychopathology) were associated with improvements in overall functioning in CAMELS (|βys| ≥ .23, ps ≤ .04). It was changes in each of the variables examined (rather than baseline values) that predicted anxiety severity and overall functioning. Conclusions Both youth and family factors play a significant role in long-term treatment outcomes. Therapists would be wise to monitor how these factors change throughout treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Findings have been mixed regarding the relationship between comorbid depression and anxiety and treatment outcomes for anxious youth. The current study compared a sample of anxious youth with a comorbid depressive disorder (n = 20) and those without comorbid depression (n = 137). All participants received 16 weekly sessions of Coping Cat and completed measures assessing anxiety/depression severity, impairment, and functioning at pretreatment and posttreatment. Results indicated that anxiety-focused CBT is efficacious for anxious youth with and without comorbid depressive disorders, with a higher rate of symptom improvement for youth with comorbid depression during treatment. However, comorbid depression was associated with higher severity at baseline and after treatment. Thus, despite the higher rate of symptom improvement, anxious youth with comorbid depression may benefit from additional treatment to address remaining symptoms.

OBJECTIVE: Accommodation, or the ways in which families modify their routines and expectations in response to a child’s anxiety, is common and interferes with anxiety treatment outcomes. However, little research has examined family accommodation among youth with autism spectrum disorder and anxiety. The current study aimed to (a) identify pre-treatment correlates of accommodation, (b) examine changes in accommodation after treatment, and (c) assess relationships between accommodation and post-treatment anxiety severity. METHOD: The sample consisted of 167 youth (mean age=9.90 years; 79.6% male; 18% Latinx) with clinically significant anxiety and a diagnosis of autism spectrum disorder who were enrolled in a randomized clinical trial comparing two cognitive behavioral therapy interventions for anxiety and treatment as usual. Participants were evaluated for symptom severity and family accommodation at pre- and post-treatment. RESULTS: Results indicated that clinician-rated anxiety severity and parent-rated externalizing behaviors and autism spectrum disorder severity significantly predicted pre-treatment accommodation. Accommodation significantly decreased from pre- to post-treatment and non-responders showed significantly higher accommodation at post-treatment compared to responders. Finally, youth with higher pre-treatment accommodation had higher post-treatment anxiety. CONCLUSIONS: Findings indicate that accommodation for anxiety is common among youth with autism spectrum disorder and anxiety. Furthermore, accommodation is implicated in treatment outcomes and should be targeted in treatment for youth with autism spectrum disorder and anxiety.

BACKGROUND: Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. METHODS: We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. RESULTS: In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. CONCLUSIONS: Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients’ access to effective treatment for anxiety disorders.

The current study explored whether patient characteristics predicted patterns of antidepressant use (i.e., never used, single episode of use, or two or more episodes) in a naturalistic follow-up. Participants in the child/adolescent multimodal (CAMS) extended long-term study. (n = 318) indicated medication use over the course of eight follow-up visits, 3-12 years after receiving treatment in CAMS. 40.6% of participants reported never using an antidepressant during follow-up, 41.4% reported a single episode of antidepressant use, and 18.0% reported multiple episodes of antidepressant use. Greater baseline anxiety severity marginally predicted a single episode of antidepressant use; baseline depression severity predicted multiple episodes of use. Reasons for discontinuing antidepressants included perceived ineffectiveness (31.8%), side effects (25.5%), and improvement in symptoms (18.5%). Exploratory analyses examined predictors of medication use. Findings suggest that antidepressant use is common among anxious youth, as is discontinuation of antidepressant use. Clinical implications and future directions are discussed.

Cognitive behavioral therapy (CBT) is well established as an efficacious treatment for anxious youth, yet a number of youth remain symptomatic after the 10–16 sessions of treatment stipulated by most CBT treatment manuals. While a significant minority do not respond, no study has examined the frequency and impact of additional therapy sessions. This study examined youth receiving outpatient therapy at an anxiety clinic who were offered the option to continue treatment after completing 16 sessions of manual-based CBT. Fifty-nine percent of participants chose to continue treatment, with an average of approximately 20 total sessions across participants. Therapist ratings demonstrated a significant overall improvement between session 16 and the final session. No pre-treatment measure of symptom severity differed between those who extended treatment and those who ended at session 16. Parent-rated anxiety differed between groups at session 16, as did the length of time between the pre-treatment assessment and week 16 assessments. Findings indicate that extending treatment is not uncommon, is typically limited to several additional sessions, and is associated with an increase in treatment gains. Current results suggest that two factors at session 16, parental perceptions of anxiety and time to complete 16 sessions, are influential and may be central to the decision to continue treatment past this point. Clinical implications and future directions are discussed.

Background: : This study examined the transition to telehealth services during the COVID-19 pandemic in terms of attendance rates, the provision of evidence-based interventions, and clinical outcomes. Methods: : The feasibility of in-person versus telehealth visits for integrated primary care sessions was compared using chart review data. Data on patient characteristics, attendance, symptom severity and improvement, and evidence-based intervention use were collected for patients (N =173) from an integrated primary clinic that primarily serves a low-income, diverse sample of adults and children whose primary presenting problems are depression and anxiety. Results: : Attendance significantly improved after the transition to telehealth, as indicated by fewer cancellations and more appointments attended. Patients showed significant improvement and decreases in symptoms. The quality of care was maintained, as indicated by consistent evidence-based intervention use over time. Limitations: : This study was limited by the fact that it took place in an academicallyaffiliated primary care clinic, which may not be representative of all community settings. In addition, analyses related to clinical symptoms were only conducted with a small subset of participants and there was no comparison group. Conclusions: : Telehealth through integrated primary care might be a viable option to improve accessibility of services for low-income, racial/ethnic minority adults and children while also leading to improvements in symptoms.

Mental health treatment in schools has the potential to improve youth treatment access. However, school-specific barriers can make implementing evidence-based interventions difficult. Task-shifting (i.e., training lay staff to implement interventions) and computer-assisted interventions may mitigate these barriers. This paper reports on a qualitative examination of facilitators and barriers of a school-based implementation of a computer-assisted intervention for anxious youth (Camp Cope-A-Lot; CCAL). Participants (N = 45) included school staff in first through fourth grades. Providers attended a training in CCAL and received weekly, hour-long group consultation calls for three months. In the second year, the sustainability of CCAL use was assessed. Qualitative interviews were conducted after the first year (initial implementation) and second year (sustainability). Interviews were analyzed using the Consolidated Framework for Implementation Research domains to classify themes. Although participants reported that CCAL included useful skills, they expressed concerns about recommended session length (45 minutes) and frequency (weekly). Time burden of consultation calls was also a barrier. School staff facilitated implementation by enabling flexible scheduling for youth to be able to participate in the CCAL program. However, the sustainability of the program was limited due to competing school/time demands. Results suggest that even with computer assisted programs, there is a need to tailor interventions and implementation efforts to account for the time restrictions experienced by school-based service providers. Optimal fit between the intervention and specific school is important to maintain the potential benefits of computer-assisted treatments delivered by lay service providers in schools.

BackgroundTrauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians’ use of TNs. The behavioral insights literature—an interdisciplinary field studying judgment and decision-making—offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants.MethodsThrough semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N= 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the “Easy Attractive Social Timely” framework, a behavioral insights design approach.ResultsWe generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation.ConclusionsOur study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.

Background:Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use – therapists’ negative beliefs about exposure – have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use.Aims:This study aimed to assess: (1) therapists’ perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training.Method:Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use.Results:Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures.Discussion:Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive–compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.

A lack of effective therapist training is a major barrier to evidence-based intervention (EBI) delivery in the community. Systematic reviews published nearly a decade ago suggested that traditional EBI training leads to higher knowledge but not more EBI use, indicating that more work is needed to optimize EBI training and implementation. This systematic review synthesizes the training literature published since 2010 to evaluate how different training models (workshop, workshop with consultation, online training, train-the-trainer, and intensive training) affect therapists' knowledge, beliefs, and behaviors. Results and limitations for each approach are discussed. Findings show that training has advanced beyond provision of manuals and brief workshops; more intensive training models show promise for changing therapist behavior. However, methodological issues persist, limiting conclusions and pointing to important areas for future research.

Direct-to-consumer (DTC) marketing strategies represent an increasingly popular approach to promote patient awareness of psychological treatments (PTs). The Marketing Mix is a well-established framework used to inform marketing decisions consisting of four “P’s”: Product (or Service), Promotion, Place, and Price. We conducted the first DTC marketing survey using the Marketing Mix framework to explore how parents concerned about their adolescents’ behavioral health receive information about PTs. A sample of 411 parents (51% girls, 82% Non-Hispanic White) of 12- to 19-year-old adolescents completed an online survey asking how they would prefer to receive information about PTs, including five questions spanning the Promotion, Price, and Place dimensions of The Marketing Mix. A subsample of 158 parents also reported on how they had received PT information during their adolescent’s most recent therapy experience, allowing us to compare ideal versus actual therapy experiences. We explored the extent to which experiences varied as a function of parent race/ethnicity, income per capita, parent education level, and adolescent treatment history. Bivariate analyses and multivariate logistic regressions were used to examine which of these variables were associated with parents’ responses to specific survey items. Analyses revealed that parent preferences varied as a function of income per capita, education level, and history of treatment. In addition, there were significant gaps between parents’ ideal and most recent therapy experiences. Implications for the marketing of PTs are discussed.

Background Implementation researchers have typically studied organizational culture and climate by testing whether individual dimensions are linked to the implementation of evidence-based practices (EBPs) rather than examining how the overarching social context influences implementation. This approach may limit implementation theory and strategy development to the extent that individual dimensions of culture and climate interact, mutually reinforce or counteract one another, or exhibit non-linear relationships. This study tests whether empirically identifiable culture and climate profiles emerge in a sample of organizations and examines how these profiles relate to EBP fidelity and work attitudes that support EBP sustainment, focusing on three EBPs for youth with autism delivered in schools as an example. Methods The study included 65 elementary schools in the U.S. that implemented three EBPs—discrete trial training, pivotal response training, and visual schedules—for youth with autism. Organizational culture and climate and work attitudes were assessed using the Organizational Social Context measure at the beginning of the school year. Observations of EBP fidelity occurred mid school-year. We used bias-adjusted stepwise latent profile modeling to (1) identify subpopulations of schools that share similar culture and climate profiles, and (2) test for mean differences across profiles in observed EBP fidelity and teacher and staff work attitudes. Results Controlling for region, four profiles best characterized the organizational cultures and climates of schools. Teachers and staff in schools with a comprehensive profile (high proficiency culture, positive climate) exhibited higher fidelity to two of three EBPs (d’s = .95 to 1.64) and reported superior work attitudes (d’s = .71 to 1.93) than teachers and staff in all other schools. Teachers and staff in supportive schools (low rigidity culture, positive climate) had better work attitudes, but not better fidelity, than those in schools with indifferent (low culture/climate, elevated stress) and constrained (high rigidity and resistance, high stress) profiles. Conclusions Organizational culture and climate profiles are a strong predictor of EBP fidelity and work attitudes that support EBP sustainment, highlighting the importance of an organization’s overarching social context when developing implementation theory and strategies. Strategies that foster a comprehensive profile may improve EBP implementation. Electronic supplementary material The online version of this article (10.1186/s13012-019-0863-9) contains supplementary material, which is available to authorized users.

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

BACKGROUND: Although exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness. METHODS: Participants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation. RESULTS: Experiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up. CONCLUSIONS: A one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions. TRIAL REGISTRATION: Clinicaltrials.gov: NCT0335497

Objective This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy. Method We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response. Results Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement. Conclusions Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record

Obsessive-Compulsive Disorder (OCD) is a neurobehavioral disorder characterized by anxiety-invoking thoughts or images (obsessions) and overt behaviors or mental rituals performed to reduce the distress caused by these thoughts (compulsions). OCD has been estimated to affect up to 2-3% of children (Valleni-Basile, Garrison, Jackson, & Waller, 1994), a figure that is likely an underestimate given that reports of “very early onset” OCD (before age 10) have only recently been documented (Garcia et al., 2009; Nakatani et al., 2011). Both studies characterizing children with very early onset OCD note similar symptom severity and a similar or greater degree of social, academic and family impairment as in children with later onset OCD. Much as the broader efforts to characterize OCD started with adults and then gradually moved down the age continuum to young children, the efforts to look for and characterize important subtypes of OCD must also be extended to include young children. Categorical, etiological and factor analytic approaches have all been used as methods to better conceptualize OCD, which remains a heterogeneous diagnosis. Among the various subtypes of OCD, patients with problematic hoarding have been identified in adults (e.g.(Eisen et al., 2013; Frost et al., 1996; Santana, Fontenelle, Yucel, & Fontenelle, 2013) and older children and adolescents (Bloch et al., 2009; Storch et al., 2007) as having distinct features and a poor treatment prognosis. In an effort toward gaining a better understanding of hoarding, distinctions have recently been made between hoarding within the context of OCD and as part of a separate disorder, Hoarding Disorder (HD), which has been added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Compulsive hoarding is characterized by difficulty discarding items, often resulting in significant distress and impairment due to excessive accumulation of clutter (Frost & Gross, 1993). Though topographically similar, Frost and colleagues (2012) outline the distinctions between hoarding in OCD and in HD. One prominent difference is in the cognitive process related to hoarding. While thoughts about hoarding are generally distressing within the context of OCD, they are neither distressing nor repetitive in HD. Hoarding within HD only becomes distressing once the amount of clutter accumulated becomes debilitating. Therefore, the act of hoarding is considered ego-syntonic in HD and ego-dystonic in OCD. While the distinction between these disorders has been a source of debate within the literature, several studies have investigated hoarding symptoms as a broader, independent construct (e.g. among people with ADHD (Hacker et al., 2012), in community samples (Samuels et al. 2008)). Regardless of diagnostic classification, there is agreement that symptoms of clinical hoarding result in significant impairment. In addition to concerns about the consequences of hoarding, its relatively high prevalence is reason for increased attention on this topic. Based on a broad definition of clinical hoarding, prevalence rates have been estimated to be between 2% and 5% of the population (Iervolino et al., 2009; Samuels et al., 2008). Among individuals with OCD, between 25% and 30% are estimated to have symptoms of compulsive hoarding (Samuels et al.,2002; Storch et al., 2007). Though hoarding symptoms are thought to first arise in childhood or early adolescence, reports about its onset and course remain predominantly retrospective (Ayers, Saxena, Golshan, & Wetherell, 2010; Grisham, Frost, Steketee, Kim, & Hood, 2006; Samuels et al. 2007). Few studies have examined specific correlates of hoarding during later childhood and adolescence (Hacker et al., 2012; Storch et al., 2007; Testa, Pantelis, & Fontenelle, 2011; See Storch, Rahman, et al., 2011 for an overview) and none have investigated hoarding during early childhood. Storch and colleagues (2007) conducted the only study to date that has used non-retrospective methods to characterize hoarding in children (ages 7-17) with OCD. Their findings suggest that, similar to adults, children with OCD and hoarding have a higher frequency of panic disorder, somatic complaints, and internalizing and externalizing behaviors than children without hoarding. In the context of developing a measure to assess hoarding severity in children (the Children's Saving Inventory; CSI), Storch, Muroff, et al. (2011) summarized additional characteristics of children with hoarding. Consistent with Storch and colleagues’ (2007) earlier study, there was a relationship between parent ratings of externalizing and internalizing behavior problems and child hoarding, but there was not a significant relationship between OCD symptom severity and hoarding. In addition, there was a weak, though significant, correlation between hoarding and anxiety symptoms. In terms of comorbidity, Testa and colleagues (2011) found that among children with learning disabilities, 16.4% of children exhibited clinically significant hoarding. Children with ADHD also exhibit higher levels of hoarding behaviors (Hacker et al., 2012). This finding is consistent with adult studies (Hartl, Duffany, Allen, Steketee, & Frost, 2005; Sheppard et al., 2010; Tolin & Villavicencio, 2011), which suggest that hoarding may be related to executive functioning and information processing deficits (Frost & Hartl, 1996; Steketee & Frost, 2003). In general, both adult and child studies indicate that individuals with hoarding symptoms exhibit lower global functioning across a variety of domains (e.g.(Mataix-Cols, Nakatani, Micali, & Heyman, 2008; Steketee & Frost, 2003). Adult hoarders have: lower Global Assessment of Functioning (GAF) scores, a higher number of suicide attempts, longer duration of illnesses, lower rates of marriage and lower levels of self-control (Santana et al., 2013; Timpano & Schmidt, 2012). Hoarding symptoms in adults and children predict persistence of OCD symptoms over time (Bloch et al., 2009; Eisen et al., 2013). Based on retrospective studies, there is also evidence for a significantly earlier age of OCD onset in those with hoarding symptoms than in those without (Fontenelle, Mendlowicz, Soares, & Versiani, 2004; Samuels et al., 2002). Individuals with hoarding symptoms have higher rates of social phobia, Generalized Anxiety Disorder (GAD), Obsessive Compulsive Personality Disorder (OCPD), Major Depressive Disorder (MDD), and compulsive buying than their non-hoarding counterparts (Chakraborty et al., 2012; Frost, Steketee, & Tolin, 2011; Frost, Tolin, Steketee, Fitch, & Selbo-Bruns, 2009; Samuels et al., 2007). Hoarders also exhibit elevated rates of chronic medical conditions, job loss, financial hardship, and obesity (Tolin, Frost, Steketee, Gray, & Fitch, 2008). Together, these findings represent significant levels of impairment, which result in substantial economic and public health burdens. Due to the accumulative nature of hoarding, it is important to gain a better understanding of its development. However, given the dearth of research on hoarding in children, additional data on clinical presentation and phenomenology of hoarding are needed to form a developmentally appropriate understanding of the behavior. The present study is a downward age extension and replication of the Storch et al. (2007) study, attempting to characterize children ages 10 and under who present with OCD and hoarding behaviors. Though additional research will be needed to characterize children with hoarding behaviors outside of OCD, the feasibility of such research is limited by the fact that few children present to treatment for hoarding behaviors in the absence of other OCD symptoms. In order to move toward a clearer understanding the distinction between hoarding in OCD and HD, we must begin by better characterizing hoarding in this group. Perhaps if hoarding can be better recognized and treated during childhood, some of its deleterious long-term effects can be mitigated.

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that often persists into adulthood. Barrett, Farrell, Pina, Peris, and Piacentini (2008), in this journal, provided a detailed review of evidence-based psychosocial treatments for youth with OCD. The current review provides an evidence base update of the pediatric OCD psychosocial treatment literature with particular attention to advances in the field as well as to the methodological challenges inherent in evaluating such findings. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the JCCAP evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, this issue). Findings from this review clearly converge in support of cognitive-behavioral therapy as an effective and appropriate first line treatment for youth with OCD (either alone or in combination with medication). Although no treatment for pediatric OCD has yet to be designated as "well-established," both individual and individual family-based treatments have been shown to be "probably efficacious." Moderators and predictors of treatment outcome are discussed as are the areas where we have advanced the field and the areas where we have room to grow. The methodological and clinical challenges inherent in a review of the evidence base are reviewed. Finally, future research directions are outlined.