Epidemiological data suggest that anxiety disorders are the most common disorders in childhood (Merikangas & Avenevoli, 2002) and place children at increased risk for other forms of dysfunction (Merikangas & Avenevoli, 2002). Fortunately, efficacious treatments, including cognitive behavioral therapy (CBT), have been identified for a variety of childhood anxiety disorders, including obsessive-compulsive disorder (Abramowitz et al., 2005, Cartwright-Hatton et al., 2004, In-Albon and Schneider, 2007, POTS, 2004 and Walkup et al., 2008). Despite the proliferation of treatment manuals to disseminate the use of CBT, evidence-based behavior therapy is not widely available in community outpatient settings (Goisman et al., 1993, Goisman et al., 1999, Storch et al., 2007 and Valderhaug et al., 2004). As a result of the limited availability of behavioral interventions, the effectiveness of treatment in clinical settings has been found to be significantly lower than the efficacy of treatment in research labs (Weisz et al., 1995 and Weisz and Jensen, 2001).
One reason for the lack of availability of evidence-based behavioral therapy is that practitioners in the community infrequently use these approaches. For instance, almost 70% of clinicians report rarely or never using treatment manuals, often citing concerns regarding the perceived length and lack of flexibility of these protocols (Addis, 2002 and Addis and Krasnow, 2000). The treatment of anxiety disorders provides a clear illustration of this disconnect between researchers and practitioners. Although there are multiple manuals describing the implementation of evidence-based procedures for childhood anxiety disorders, including obsessive-compulsive disorder (OCD; e.g., Kendall, 2000 and March and Mulle, 1998), these procedures are rarely used in community settings (Storch et al., 2007 and Valderhaug et al., 2004).
The responsibility for increasing the use of empirically based interventions may not rest solely with the practitioner. Despite the fact that many researchers emphasize the importance of exposures (Barlow, 1988, Beidel et al., 2000, Davis and Ollendick, 2005, Kazdin and Weisz, 1998, Kendall et al., 2005, Marks, 1969 and Silverman and Kurtines, 1996), many manualized treatments for childhood anxiety do not clearly deliver this message. Instead, most manuals begin with anxiety management skills (e.g., cognitive restructuring, relaxation training) before beginning exposures. For example, the most recognizable treatment for childhood anxiety disorders, The Coping Cat (Kendall, 2000), begins with eight sessions to develop an anxiety management plan, followed by eight sessions of graduated exposures. Manuals for the treatment of OCD follow a similar format, although exposure exercises are typically initiated as early as the fourth session (e.g., March & Mulle, 1989). Although other treatments place a clear emphasis on exposures (Beidel et al., 2000 and Chorpita, 2007), the manuals that have been held up as the standard barriers for the field in randomized controlled trials, and thus likely receive the most press, have followed a format of cognitive work followed by exposure (e.g., Walkup et al., 2008).
When faced with a multifaceted treatment program without guidelines regarding which components are the most effective, it is perhaps understandable that clinicians view manualized treatments as long and inflexible. As a result, practitioners may decide to select a limited number of CBT techniques and end up focusing on non-exposure-based strategies that are less distressing (for patient and therapist) and easier to administer in the office. In fact, even practitioners who endorse using CBT also report rarely using exposures and instead focus more on cognitive techniques and relaxation (Freiheit et al., 2004, Goisman et al., 1993 and Valderhaug et al., 2004). This is unfortunate given that a recent review of meta-analyses of treatments for adult anxiety concluded that there is strong support for behavioral treatment (e.g., exposures) but that, at least for some disorders, there does not appear to be increased benefit from adding cognitive techniques ( Deacon & Abramowitz, 2004).
To overcome these obstacles, multiple researchers have encouraged the conduction of treatment outcome research by front-line practitioners and clinics with an increased focus on external validity (Addis, 2002, Green, 2008, Hatgis et al., 2001 and Weisz et al., 1995). Consistent with this approach, the current study examines the content of clinic-based treatment for childhood anxiety disorders in an effort to influence clinicians and researchers to develop and implement flexible empirically based treatments. Specifically, the content of clinic-based treatment was compared to prominent protocols for the treatment of childhood anxiety disorders and OCD. In addition, the relation between therapeutic techniques and treatment outcome, measured by symptom reduction and improvement in functioning, was also examined. It was hypothesized that clinic-based treatment would be shorter in duration and include exposure exercises earlier in the course of treatment than published protocols while achieving significant symptom improvement. In addition, it was predicted that the degree to which exposures were used in treatment would be positively related to the amount of symptom improvement. Finally, exploratory analyses were conducted to investigate factors that might influence the use of treatment techniques.
