Exposure Therapy for Children with Anxiety and OCD : Clinician's Guide to Integrated Treatment

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