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Overlapping and Non-overlapping Practices in Usual and Evidence-Based Care for Youth Anxiety

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Abstract

This study compared consistencies and discrepancies in usual care with practices derived from the evidence-base (PDEB) for youth anxiety in a public mental health system. Youth-level factors (diagnosis, functional impairment) as predictors of the discrepancies were also examined. Psychosocial and service data from 2485 youth with an anxiety disorder and/or receiving services for an anxiety treatment target were extracted. Therapists (N = 616) identified the treatment targets and practices youth received. Although many PDEB for youth anxiety were used by therapists in this sample, Exposure was only used in 15% of cases. Practices not consistent with youth anxiety treatment were also reported and included: PDEB for other conditions, practices common to all therapies, and practices that are not consistent with evidence-based care. Age and diagnosis predicted the delivery of PDEB for youth anxiety. Usual care incorporated many components of evidence-based care but was more diffuse and less focused on well-supported practices.

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Notes

  1. The treatment target of traumatic stress was not included in this analysis as it was the primary focus of a different study by Borntrager and colleagues.4 Similarly, diagnoses of post-traumatic stress disorder were also excluded from this study.

  2. The practice profile for youth with a primary anxiety disorder only was nearly exactly the same as the profile for the broader anxiety sample so only the practice profile for the broad sample is presented. The practice profile by primary anxiety only is available upon request.

  3. This list includes practices showing up in 10% or more of level 2 treatments.

    Child and Adolescent Mental Health Division. (2008). Service Provider Monthly Treatment and Progress Summary.

    Chorpita BF, Daleiden EL. Results from the 2007 Biennial Report: Effective Psychosocial Interventions for Youth with Behavioral and Emotional Needs. Honolulu, Hawai’i Department of Health, Child and Adolescent Mental Health Division, 2007.

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Authors and Affiliations

Authors

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Correspondence to Charmaine Higa-McMillan PhD.

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Conflict of Interest

The first author was employed by the Child and Adolescent Mental Health Division, Hawai‘i State Department of Health during the time when data was collected for this study. The second author has no disclosures. The third author is currently employed under a contract with the Child and Adolescent Mental Health Division, Hawai‘i State Department of Health. The fourth author is an officer and has ownership interests in Kismetrics, LLC and PracticeWise, LLC, which provide information resources, training, and consulting services related to the common practice elements and evidence-based services addressed in this manuscript. He was also working as a consultant to the Child and Adolescent Mental Health Division during performance of this project.

Appendix

Appendix

Description of Practices Derived from the Evidence-Base for Youth AnxietyFootnote 3

  1. 1.

    Exposure – Techniques or exercises that involve direct or imagined experience with a target stimulus, whether performed gradually or suddenly, and with or without the therapist’s elaboration or intensification of the meaning of the stimulus.

  2. 2.

    Cognitive – Any techniques designed to alter interpretation of events through examination of the child’s repeated thoughts, typically through the generation and rehearsal of alternative counter-statements. This can sometimes be accompanied by exercises designed to comparatively test the validity of the original thoughts and the alternative thoughts through the gathering or review of relevant information.

  3. 3.

    Psychoeducational-Child – The formal review of information with the child about the development of a problem and its relation to a proposed intervention.

  4. 4.

    Relaxation – Techniques or exercises designed to induce physiological calming, including muscle relaxation, breathing exercises, meditation, and similar activities. Guided imagery exclusively for the purposes of physical relaxation is also coded here.

  5. 5.

    Modeling – Demonstration of a desired behavior by a therapist, confederates, peers, or other actors to promote the imitation and subsequent performance of that behavior by the identified youth.

  6. 6.

    Psychoeducational-Parent – The formal review of information with the caregiver(s) about the development of the child’s problem and its relation to a proposed intervention. This often involves an emphasis on the caregiver’s role in either or both.

  7. 7.

    Self-Monitoring – The repeated measurement of some target index by the child.

  8. 8.

    Therapist Praise/Rewards – The administration of tangible (i.e., rewards) or social (e.g., praise) reinforcers by the therapist.

  9. 9.

    Self-Reward/Self-Praise – Techniques designed to encourage the youth to self-administer positive consequences on performance of target behaviors.

  10. 10.

    Maintenance/Relapse Prevention – Exercises and training designed to consolidate skills already developed and to anticipate future challenges, with the overall goal to minimize the chance that gains will be lost in the future.

  11. 11.

    Problem Solving – Techniques, discussions, or activities designed to bring about solutions to targeted problems, usually with the intention of imparting a skill for how to approach and solve future problems in a similar manner.

  12. 12.

    Assertiveness Training – Exercises or techniques designed to promote the child’s ability to be assertive with others, usually involving rehearsal of assertive interactions.

  13. 13.

    Tangible Rewards – The training of parents or others involved in the social ecology of the child in the administration of tangible rewards to promote desired behaviors. This can involve tokens, charts, or record keeping, in addition to first-order reinforcers.

  14. 14.

    Relationship/Rapport Building – Strategies in which the immediate aim is to increase the quality of the relationship between the youth and the therapist. Can include play, talking, games, or other activities.

  15. 15.

    Social Skills Training – Providing information and feedback to improve interpersonal verbal and non-verbal functioning, which may include direct rehearsal of the skills.

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Higa-McMillan, C., Kotte, A., Jackson, D. et al. Overlapping and Non-overlapping Practices in Usual and Evidence-Based Care for Youth Anxiety. J Behav Health Serv Res 44, 684–694 (2017). https://doi.org/10.1007/s11414-016-9502-2

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