Nov. 10, 2015
Anxiety disorders and pediatric obsessive-compulsive disorder (OCD) can profoundly affect the social, academic and family functioning of children and adolescents. Exposure-based therapy, an evidence-based treatment that encourages the systematic confrontation of feared stimuli, is the most well-researched and effective psychosocial intervention for these disorders and is considered a first line treatment for them.
Exposure usually follows anxiety management strategies (AMS) in standard cognitive behavioral therapy (CBT), but research suggests that delaying exposure for six or more sessions, as is commonly done in the AMS-followed-by-exposure model, may make CBT less effective and that AMS alone may not be better than placebo.
A study by Mayo Clinic researchers published in Behavior Research and Therapy in 2015 found that using parent-coached exposure without AMS not only is safe and tolerable but also results in greater improvement in fewer sessions. Still, parent-coached exposure therapy is rarely available, according to lead study author Stephen P. Whiteside, Ph.D., L.P., director of the Pediatric Anxiety Disorders Clinic at Mayo Clinic's campus in Minnesota.
"For the past 20 years, researchers have been developing treatments that include many different techniques and clinicians have been focusing on the other aspects instead of exposure. What we are doing at Mayo Clinic is different," he says.
Mayo's approach consists of approximately eight weekly sessions of parent-coached exposure therapy, although the length of treatment can vary, depending on the severity of symptoms. Parents are actively involved in treatment from the beginning, so they develop the tools and confidence to support their child's efforts between appointments.
"The hope is that if parents can help their children do more and better quality exposures between appointments, they will have to see us less often," Dr. Whiteside explains. "We aim for one exposure a day, and families are pretty successful at achieving this."
Many families aren't able to attend weekly sessions at specialty clinics, however. One alternative is to provide intensive treatment — daily sessions over a short time frame — that allows families to travel to a specialty clinic and stay there during treatment. Although intensive protocols, which typically last three weeks, may be an option for some patients, they aren't feasible for others.
In 2010, Mayo researchers tested the feasibility of a five-day treatment protocol and found its effectiveness was similar to standard weekly and three-week intensive treatments. A more rigorous follow-up study, published in Psychiatry Research in 2014, documented significant improvement with the five-day protocol in three critical areas:
- Symptom severity
- Functional impairment
- Family accommodation
All symptom measures continued to decrease from post-treatment to follow-up, perhaps due to ongoing parent involvement as exposure coaches.
"Our protocol is shorter because we prepare families to continue exposure therapy on their own," Dr. Whiteside says. "The work children and adolescents put into the program is inspiring, and many work up to their highest fears during that week. We started the five-day intensive treatment with pediatric obsessive-compulsive disorder, and in response to patient needs, we have now expanded it to include all anxiety disorders."
In an effort to further improve access to evidence-based care for pediatric OCD and anxiety disorders, Dr. Whiteside co-developed the Mayo Clinic Anxiety Coach app, a self-help tool for iOS. The app includes:
- Information about anxiety disorders, exposure therapy and finding a therapist
- A short self-test to measure symptom severity
- A library of more than 500 exposure activities to help master a wide range of fears, including social anxiety, separation anxiety, trauma-related anxiety and obsessive-compulsive disorder
- The ability to track anxiety during exposure and to record and view patient progress
"The app is accessible enough that people can use it on their own, and if they are interested in therapy, it can help them know what to look for in a therapist," Dr. Whiteside explains. "It can also help therapists who are less experienced in exposure therapy learn how to create fear ladders."
In-person treatment, whether weekly or the five-day protocol, remains the gold standard, however. Physicians wishing to refer patients can contact Dr. Whiteside directly at 507-293-0089 or firstname.lastname@example.org.
For more information
Whiteside SPH, et al. The feasibility of improving CBT for childhood anxiety disorders through a dismantling study. Behaviour Research and Therapy. 2015;73:83.
Whiteside SPH, et al. A baseline controlled examination of a 5-day intensive treatment for pediatric obsessive-compulsive disorder. Psychiatry Research. 2014;220:441.