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Studies characterizing Orthostatic Intolerance (OI) have primarily focused on a specific subtype (e.g., Postural Orthostatic Tachycardia Syndrome, POTS) treated in tertiary care, yet many with impairing symptoms do not meet subtype criteria. Study 1 used structured coding of electronic medical records to explore symptoms and impairment among 226 youth with OI in a common care setting (outpatient cardiology) over a 1-year period. Impairment was evident for 54.7% of youth. Greater impairment was associated with female gender, higher number and frequency of symptoms, and specific symptoms of headache, weakness, or exercise intolerance. Study 2 examined symptoms, functional disability, and treatment interest in a subset of youth from Study 1 (n = 75); data were collected 1–2 years after initial visit via phone interview. Fifty-six percent of participants remained symptomatic, with mean disability exceeding "substantial impairment" and most (78.6%) expressing desire for treatment. Greater disability was associated with more symptoms and the symptom of weakness. Critically, disability was more than twice as high among racial and ethnic minority youth. Results suggest that OI impairment is common among youth in secondary care, and many experience symptoms warranting treatment 1–2 years later. Future studies should identify sources of health disparities and develop efficacious treatments. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 posttreatment 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. [ABSTRACT FROM AUTHOR]

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors that have been associated with youth outcomes in prior clinical trials of exposure therapy. Sixteen therapists in practice settings treated 46 youths with an anxiety disorder or obsessive-compulsive disorder (OCD). Therapists were randomly assigned to receive "gold-standard" exposure therapy training with weekly consultation (GS) or "gold-standard" training with weekly consultation plus the EG (EG). The primary outcome was therapist behavior during in-session exposures, observed using a validated coding system. Secondary outcomes included training feasibility/acceptability and observer-rated patient fear habituation; we also explored independent evaluator-rated clinical outcome. As hypothesized, therapists used similarly high rates of exposure with patients in both groups, but those in the EG condition used more fear-increasing behaviors and fewer fear-decreasing behaviors compared with those in the GS condition. Attendance data and therapist feedback support EG feasibility and acceptability. Patients treated by EG-trained therapists showed increased rates of in-session habituation. Descriptive clinical outcome data showed a slightly higher treatment response rate in the EG group (66.7% EG, 58.8% GS) that was more pronounced among patients completing a posttreatment assessment (83.3% EG, 60.0% GS). Results confirm the effectiveness of EG training for improving therapist delivery behaviors. Future studies will be needed to determine whether EG training can improve rates of patient treatment response via improved delivery behaviors. Public Health Significance: This study shows that the Exposure Guide, a therapist training tool, improves therapist delivery of exposure. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The present study developed parallel clinician- and parent-rated measures of family accommodation (Pediatric Accommodation Scale, PAS; Pediatric Accommodation Scale-Parent Report; PAS-PR) for youth with a primary anxiety disorder. Both measures assess frequency and impact of family accommodation on youth and families. Studying youth ages 5–17 ( N = 105 caregiver-youth dyads), results provide evidence for the psychometric properties of the PAS, including internal consistency, inter-rater reliability, and convergent and discriminant validity. The PAS-PR exhibited good internal consistency and convergent validity with the PAS. Nearly all parents (>95%) endorsed some accommodation and accommodation frequency was associated with parent-rated impairment (home and school), and with youth-rated impairment (school only). Greater impact of accommodation on parents was associated with parent self-reported depressive symptoms. Findings support the common occurrence of family accommodation in youth with anxiety disorders, as well as for the use of the PAS and PAS-PR to measure family accommodation in this population. [ABSTRACT FROM AUTHOR]

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum – with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings. [ABSTRACT FROM AUTHOR]

Anxiety disorders are the most common mental health problem in youth, and accommodation is prevalent among youth with anxiety disorders. The Pediatric Accommodation Scale (PAS) is an interview administered by trained evaluators and a parent-report form (PAS-PR) to assess accommodation and its impact. Both have strong psychometric properties including internal consistency, inter-rater reliability, and data supporting construct validity. The present study evaluates the Pediatric Accommodation Scale – Therapist Report (PAS-TR), a therapist-reported version of the PAS-PR. Participants were 90 youth enrolled in cognitive behavioral therapy for anxiety. Therapists completed the PAS-TR over 16 therapy sessions. Internal consistency at baseline, convergent validity, divergent validity, and parent-therapist agreement were evaluated. Results suggest that the PAS-TR has mixed psychometric qualities suggesting that while not strong prior to the initiation of treatment, the PAS-TR may be a useful measure for therapists to rate accommodation as treatment progresses. Implications for assessment, treatment, and research are discussed. [ABSTRACT FROM AUTHOR]

The Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II) investigated the benefit of serotonin reuptake inhibitor (SRI) augmentation with cognitive behavioral therapy (CBT). Primary outcomes focused on OCD symptom change and indicated benefit associated with a full course of CBT. Given that the majority of youth with OCD suffer from significant comorbid symptoms and impaired quality of life, the current study examined POTS II data for effects on secondary outcomes. Participants were 124 youth ages 7–17 years with a primary diagnosis of OCD who were partial responders to an adequate SRI trial. Participants were randomized to medication management, medication management plus instructions in cognitive behavioral therapy (CBT), or medication management plus full CBT. Acute effects on non-OCD anxiety, depression, inattention, hyperactivity, and quality of life were examined across treatment conditions. Improvement across treatment was observed for non-OCD anxiety, inattention, hyperactivity, and quality of life. Changes were generally significantly greater in the group receiving full CBT. Child-rated depression was not found to change. OCD-focused treatment lead to improvement in other areas of psychopathology and functioning. For youth who are partial responders to SRI monotherapy, augmentation with full CBT may yield the greatest benefit on these secondary outcomes. Clinical trials registration Treatment of Pediatric OCD for SRI Partial Responders, Clinicaltrials.gov Identifier: NCT00074815, http://clinicaltrials.gov/show/NCT00074815 . [ABSTRACT FROM AUTHOR]

Cognitive behavioral therapy (CBT) is an efficacious therapy for youth anxiety disorders. Caregivers are key stakeholders in youth therapy, and their feedback on treatment can help to inform intervention personalization. This mixed-methods study applied a systematic inductive thematic analysis to identify themes among most- and least-liked CBT features reported by caregivers using open-ended responses on the Client Satisfaction Questionnaire (CSQ-8). The sample included 139 caregivers of youth ages 7–17 (M = 12.21, SD = 3.05; 59% female; 79.1% Caucasian, 5.8% Black, 2.9% Asian, 2.2% Hispanic, 7.9% Multiracial, 2.2% Other) with principal anxiety diagnoses who completed 16-sessions of CBT. CSQ-8 quantitative satisfaction scores (M = 29.18, SD = 3.30; range : 16–32) and survey-based treatment response rates (responders n = 93, 67%) were high. Most-liked treatment features included: coping skills (i.e., exposure, understanding/identifying anxiety, rewards, homework), therapist factors (interpersonal style/skill, relationship, accessibility), caregiver involvement, one-on-one time with a therapist, structure, consistency, and personally tailored treatment. Least-liked treatment features included: questionnaires, logistical barriers, telehealth, need for more sessions, non-anxiety concerns not addressed, insufficient caregiver involvement, and aspects of exposure tasks. Proportional frequencies of most- and least-liked themes differed by treatment responder status (e.g., responders cited exposure and homework as most-liked more frequently). • Caregivers liked cognitive behavioral therapy for youth anxiety. • For most-liked treatment features, caregivers cited exposures, particularly caregivers of youth who responded to treatment, and a need for flexibility within fidelity in treatment delivery. • Least-liked treatment features were few, but included a dislike of telehealth and other logistical concerns. [ABSTRACT FROM AUTHOR]