Citation
Dissemination of Therapist-Assisted in Vivo Exposure Therapy in a Sample of Community Practitioners

Material Information

Title:
Dissemination of Therapist-Assisted in Vivo Exposure Therapy in a Sample of Community Practitioners
Creator:
Reid, Adam M
Publisher:
University of Florida
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Epidemiology
Committee Chair:
STRILEY,CATHERINE L
Committee Co-Chair:
VADDIPARTI ANANTH,SRINIVASA KRISHNA
Committee Members:
GEFFKEN,GARY R
Graduation Date:
8/8/2015

Subjects

Subjects / Keywords:
anxiety
community
dissemination
therapist
treatment
Anxiety ( jstor )
Post traumatic stress disorder ( jstor )
Obsessive compulsive disorder ( jstor )
Genre:
Unknown ( sobekcm )

Notes

General Note:
Exposure-based techniques, despite their empirical support, are rarely utilized by community practitioners who treat adult anxiety disorders such as OCD, PTSD, PD, and SAD. The present study sought to identify how often TAIVE, the most effective exposure-based technique, is utilized by community-based practitioners around the United States who treat children and adolescents with OCD, PTSD, PD and/or SAD. Furthermore, this study aimed to identify therapist level predictors of TAIVE utilization. Data were collected on 302 community-based practitioners from around the United States. In general, community-based practitioners appear to favor most CBT-ET techniques except TAIVE for the treatment of pediatric anxiety disorders. Practitioners reported using TAIVE between 12% (for PTSD) and 31% (for OCD) of the time when they treated a child or adolescent with OCD, PTSD, PD, or SAD over the last year. Training in exposure therapy and negative beliefs about exposure therapy appear to be the strongest predictor of TAIVE use. When considered in the context of the diffusion of innovation principle, the data suggest that dissemination of TAIVE is at a critical junction and future research needs to identify the best methods to improve negative attitudes and beliefs about exposure-based treatments in community providers in order to increase dissemination.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Reid, Adam M. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Embargo Date:
8/31/2017

Downloads

This item has the following downloads:


Full Text

PAGE 1

DISSEMINATION OF THERAPIST ASSISTED IN VIVO EXPOSURE THERAPY IN A SAMPLE OF COMMUNITY PR ACTITIONERS By ADAM MICHAEL REID A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2015

PAGE 2

2015 Adam Michael Reid

PAGE 3

To those with mental illness who do not have access to mental healthcare

PAGE 4

4 ACKNOWLEDGMENTS pidemiology would not have been possible without Drs. Catherine Striley, Joseph McNamara and Gary Geffken who all supported me in my effort to broaden my education and contributed substantially to the success of this project. I would like to especially thank Ms. Alyka Fernandez who was the study coordinator for this project and has an unwavering passion to improve ac cess to quality mental healthcare for the medically underserved Finally, I also would like to thank Mrs. Amanda Balkhi, Mr. Andrew Guzick, and all the undergraduates in the Division of Medical Psychology research lab who spent countless hours contributing to this project.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLE DGMENTS ................................ ................................ ................................ ............... 4 LIST OF TABLES ................................ ................................ ................................ ........................... 7 LIST OF FIGURES ................................ ................................ ................................ ......................... 8 LIST OF ABBREV IATIONS ................................ ................................ ................................ .......... 9 ABSTRACT ................................ ................................ ................................ ................................ ... 10 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .................. 11 Dissemination of Exposure Therapy ................................ ................................ ...................... 12 Predictors of Exposure Therapy Dissemination ................................ ................................ ..... 14 Study Aims ................................ ................................ ................................ ............................. 17 2 METHODS ................................ ................................ ................................ ............................. 18 Participants ................................ ................................ ................................ ............................. 18 Procedure ................................ ................................ ................................ ................................ 19 Measures ................................ ................................ ................................ ................................ 20 Utilization Rates for Exposure based Techniques ................................ .......................... 20 Training in Exposure based Techniques ................................ ................................ ......... 21 Disgust Sensitivity ................................ ................................ ................................ ........... 21 Anxiety Sensitivity ................................ ................................ ................................ .......... 21 Negative Attitudes and Beliefs ................................ ................................ ........................ 22 Statistical Analyses ................................ ................................ ................................ ................. 22 3 RESULTS ................................ ................................ ................................ ............................... 24 Aim 1. Treatment Utilization Patterns ................................ ................................ .................... 24 Aim 2. Predictors of Therapist Assisted Exposure based Technique Use ............................. 25 Preliminary Analyses ................................ ................................ ................................ ....... 25 Linear Regression Analyses ................................ ................................ ............................ 26 Therapist Assisted In Vivo Exposure Use for Pediatric Obsessive Compulsive Disorder ................................ ................................ ................................ ........................ 26 Therapist Assisted In Vivo Exposure Use for Pediatric Post Traumatic Stress Disorder ................................ ................................ ................................ ........................ 27 Therapist Assisted In Vivo Exposure Use for Pediatric Panic Disorder .......................... 28 Th erapist Assisted In Vivo Exposure Use for Pediatric Social Anxiety Disorder ........... 29 4 DISCUSSION ................................ ................................ ................................ ......................... 39

PAGE 6

6 REFERENCES ................................ ................................ ................................ .............................. 48 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ......... 57

PAGE 7

7 LIST OF TABLES Table page 3 1 Treatment utilization patterns for pediatric anxiety disorders ................................ ........... 31 3 2 Correlations among independent variables ................................ ................................ ........ 33 3 3 Correlations of study independent and dependent variables ................................ .............. 34 3 4 Predictors of therapist assisted in vivo exposure for OCD ................................ ................ 35 3 5 Predictors of therapist assisted in vivo exposure for PTSD ................................ ............... 36 3 6 Predictors of therapist assisted in vivo exposure for PD ................................ ................... 37 3 7 Predictors of therapist assisted in vivo exposure for SAD ................................ ................. 38

PAGE 8

8 LIST OF FIGURES Figure page 4 1 TAIVE as a therapeutic tool for pediatric anxiety disorders, a frequency cut off was utilized based off treatment manuals for the various disorders.. ................................ ....... 47

PAGE 9

9 LIST OF ABBREVIATIONS CBT ET cognitive behavioral therapy with exposure t herapy OCD obsessive c ompulsive d isorder PTSD post traumatic stress d isorder PD panic d isorder SAD social anxiety d isorder TAIVE therapist a ssisted in v ivo e xposure

PAGE 10

10 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science DISSEMINATION OF THERAPIST ASSIST ED IN VIVO EXPOSURE THERAPY IN A SAMPLE OF COMMUNITY PRACTITIONERS By Adam Michael Reid August 2015 Chair: Catherine W. Striley Major: Epidemiology Exposure based techniques despite their empirical support, are rarely utilized by community practitioners who treat adult anxiety disorders such as OCD, PTSD PD, and SAD The present study sought to identify how often TAIVE the most effective exposure based technique, is utilized by community based practitioners around the United States who treat children and adolescents with OCD, PTSD, PD and/or SAD. Furthe rmore, this study aimed to identify therapist level predictors of TAIVE utilization. Data w ere collected on 302 community based practitioners from around the United States. In general, community based practitioners appear t o favor most CBT ET techniques ex cept TAIVE for the treatment of pediatric anxiety disorders Practitioners reported using TAIVE between 12% (for PTSD) and 31% (for OCD) of the time when they treated a child or ado lescent with OCD, PTSD, PD, or SAD over the last year. Training in exposure therapy and n egative beliefs about exposure therapy appear to be the strongest predictor of TAIVE use When consider ed in the context of the diffusion of innovation principle the data suggest that dissemination of TAIVE is at a critical junction and futu re research needs to identify the best methods to improve negative attitudes and beliefs about exposure based treatments in community providers in order to increase dissemination.

PAGE 11

11 CHAPTER 1 INTRODUCTION Anxiety disord ers are among the most common psychiatric illnesses in children and adolescents, with over 8% of youth in the United States reporting at least one anxiety disorder by the age of 18 (Merikangas et al., 2010). Pediatric anxiety disorders lead to immense dist ress and impairment in school, social, and family functioning (Kendall et al., 2010 ; Piacentini, Ber gman, Keller, & McCracken, 2003 ). When left untreated, anxiety disorders often run a chronic course (Keller et al., 1992; Perkonigg et al., 2014 ; Pine, Co hen, Gurley, Brook, & Ma, 1998 ; Rapee, Schniering, & Hudson, 2009 ) and are associated with the development of secondary psychiatric conditions such as depression ( Pine et al., 1998 ) and substance abuse ( Woodward & Fergusson, 2001). By most recent estimate s societal costs due to anxiety disorders exceeded $42 billion per decade (Greenberg et al., 1999). The American Academy of Child and Adolescent Psychiatry ( Connolly & Bernstein, 2007 ) and other leading organizations (American Psychiatric Association, 20 11; Institute of Medicine, 2011) have identified CBT ET as the first line psychotherapeutic treatment for pediatric anxiety disorders These expert guidelines are grounded in repeated empirical evidence that supports CBT ET as an efficacious intervention f or these disorders (e.g. Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012 ; James, Soler, & Weatherall, 2013 ; Rodebaugh, Holaway, & Heimberg, 2004 ; Jordan, Reid, Mariaskin, Augusto, & Sulkowski, 2012), superior to other psychological (e.g., Siev & Chambless, 2 007; Piacentini et al., 2011) and psychopharmacological treatments ( e.g., Pediatric OCD Treatment Study Team 2004; Bandelow, Seidler Brandler, Becker, Wedekind, & Rther, 2007; Walkup et al., 2008). For example, a recent study by the University of Florida and the University of South Florida found that after 14 weeks of CBT ET, patients obsessive compulsive symptoms had decreased from

PAGE 12

12 Storch et al., 2013 ). Therefore, widespread dissemination of CBT ET techniques is critical. Given that 60% percent of children and adolescents receive psychological care from community providers, the familiarity and comfort of community providers with CBT ET is crucial in order to address this notable public health concern and increase access to quality mental healthcare for children and adolescents with anxiety disorders ( Simpson, Cohen, Pastor, & Reuben, 2008 ). Community practitioners include anyone who provides mental health services outside of an academic setting (e.g., private practice, community based hospitals). Dissemination of Exposure Therapy E xposure based techniques a key ingredient of CBT ET for anxiety disorders (Abramowitz, Deacon, & Whiteside, 2010; Craske et al., 2008 ; Foa & Kozak, 1986; Lohr, Lilienfeld, & Rosen, 2012), involve helping patient s approach a fe ared stimulus and/or environment in a systematic manner so that fears can be modified as a result of arousal reduction ( Foa & Kozak, 1986 ) and/or distress tolerance ( Craske et al., 2008 ) Unfortunately, exposure based techniques are rarely utilized by community providers to treat anxiety disorders (Becker Zayfert, & Anderson, 2004; Bhm & Klz, 2008; Cook, Biyanova, Elhai, Schnurr, & Coyne, 2010 ; Freiheit Vye, Swan, & Cady, 2004; Hipol & Deacon, 2013 ; van Minnen, Hendriks, & Olff, 2010 ). Exposure based techniques are us ed muc h less often than the majority of the other CBT ET techniques ( Freiheit et al. 2004; Hipol & Deacon, 2013 ) at rates comparable or les s er than several non empirically supported te chniques (e.g., thought field therapy; Hipol & Deacon, 2013). Even when exposure based techniques are utilized, they often are combined with theoretically inconsistent techniques (e.g., arousal reduction strateg ies; Hipol & Deacon, 2013) or delivered in a less intense format (e.g., taking breaks between inter o ceptive exposures for PD; Deacon Lickel Farrel l, K emp & Hipol 2013 ). In general, a growing body of literature suggests

PAGE 13

13 a large gap between what is most e mpirically supported (i.e., TAIVE ) and what is generally utilized by community providers to treat anxiety disorders. Various exp osure based techniques exist that vary in how they facilitate a pproach to a fea red st imuli and/or environment Specifically, in vivo exposure involves physically engaging with a feared stimul us and/ or environment while in vitro exposure (e.g., imaginal exposure ) involves the patient visualizing themselves in a feared situation and/ or environment. Consistent with behavioral literature ( e.g., Bouton, 2002 ) in vivo exposure has been shown to be more effective than in vitro exposure ( Armfield, 2008; st, Ferebee, & Furmack, 1997 ; Ultee, Griffioen, & Schellekens, 1982 ). Unfortunately, t he limited research on the dissemination of various exposure techniques suggests that in vitro exposure is utilized more often than in vivo exposures by community practitioners who treat anxiety disorders ( Hipol & Deacon, 2013 ). More so, a ll in vivo exposure is either practitioner assisted (e.g., practitioner is alongside the patient throughout the exposure coaching them on how to best engage the feared stimuli and/or environment) or patient directed (e.g., practitioner assigns exposure for patient to conduct without the practitioner physically present ). The former approach will be referred to as TAIVE while the latter will be referred to as client self directed in vivo exposure in this study Research suggests that community pr actitioners use client self directed in vivo exposure more than TAIVE ( Hipol & Deacon, 2013 ), although TAIVE is more empirically supported ( Abramowitz, 1996 ; Abramowitz, Franklin, & Foa, 2002 ). Among other reasons, TAIVE is more effective because it allows the practitioner to im mediately tailor the exposure based on verbal and physiological feedback from the patient and lets the therapist to model the exposure activity to the patient. Two other exposure based techniques that have empirical support are interoceptive exposure for PD ( exposure to physiological sensations often experienced during panic attacks;

PAGE 14

14 Angelosante, Pincus, Whitton, Cheron, & Pian, 2009; Pincus, May, Whitton Mattis, & Barlow, 2010) and trauma focused narrative for PTSD ( exposure to a trauma related script; Deblinger et al., 2011; TF CBT Web, 2005). Following the data above, other non exposure techniques are often implemented rather than interoceptive exposure for PD ( Hipol & Deacon, 2013 ) and trauma focused narrative for PTSD ( Allen & Johnson, 2011 ; Woody, A nderson, D'Souza, Baxter, & Schubauer, 2015 ). This evidence suggests that even when community providers do use exposure based techniques they often do so in a sub optimal manner. Predictors of Exposure Therapy Dissemination Due to the poor dissemination of exposure based techniques, a growing body of research has sought to identify barriers to the dissemination of these techniques. Practitioner specific factors (e.g., negative attitudes) rather than organizational (e.g., work place po licies) or patient related factors (e.g., preference for other treatment) are argued to be the primary barrier to dissemination of exposure based practices (Harned, Dimeff, Woodcock, & Contreras 2013). For example patients actually report a prefer ence f or exposure based techniques over other psychological and pharmacological treatment options ( Becker, Darius, & Schaumberg, 2007 ; Brown, Deacon, Abramowitz, Dammann, & Whiteside, 2007; Feeny, Zoellner, Mavissakalian, & Roy Byrne, 2009; Lewin, McGuire, Murph y, Storch, 2014; Patel & Simpson, 2010; Tarrier, Liversidge, & Gregg 2006 ). Training in exposure therapy is an important therapist related factor that is associated with dissemination. Logically, community pr actitioners who receive training in exposure b ased techniques are more likely to utilize them and conduct them in an optimal manner (Becker et al., 2004; Deacon et al., 2013; Deacon et al., 2013; Gunter & Whittal, 2010; Harned et al., 2014; Sholomskas et al., 2005 ). However, exposure specific training is not a panacea for the poor dissemination of CBT ET (Becker, Zayfert, & Anderson, 2004). O ther demographic factors

PAGE 15

15 appear to be associated with dissemination. For example, women appear to use exposure based techniques less than males (Sprang et al., 2008; van Minnen et al., 2010), possibly due to higher e mpathy for patients (Davis, 1983 ). Furthermore, p ractitioners with a higher academic degree are more likely to utilize exposure based techniques (Harned et al., 2013). One study found that practitioners who identify themselves as anxiety specialist s were more likely to use imaginal exposures but not other techniques such as TAIVE (Hipol & Deacon, 2013 ). Considering the association between higher self efficacy and more ex posure utilization (Harned et al., 2013), it is probable that a study with a larger sample will find a more consistent link between self identifying as an anxiety specialist and higher use of exposure based techniques Practitioner temperament and perc eption of exposure based techniques are two additional factors that may contribute to poor CBT ET dissemination. For instance practitioners with higher anxiety sensitivity appear to be more hesitant about the implementation of exposures (Harned et al., 2013). Indeed, psychologists often worry about their own reactions to exposure based techniques such as fear ing that they would not be able to handle watching their patient endure the anxiety provoking situation (Zoellner et al., 2011). O ne related aspect of temperament that has not been researched is practitioner disgust sensitivity (i.e., predisposition to experience disgust) which serves a disease avoidance function in humans (Matchett & Davey, 199 1 ; Oaten, Stevenson, & Case, 2009 ) and could theoretically make practitioners mor e hesitant to conduct disgust provoking exposures (Deacon & Olatunji, 2007) Notably, less anxiety and disgust sensitivit y are both associated with more training in exposure based techniques ( Guzick et al., 2015 ) which could suggest that some practitioners have a temperamental predisposition towards being receptive to exposure based techniques.

PAGE 16

16 Negative attitudes and beliefs about exposures have the largest backing in the literature as a barrier to dissemination of exposure based techniques P roviders may object to exposure because they believe that it violates Deacon, & Abramowitz, 2009), that it could exacerbate symptoms and lead to high dropout rates (O latunji, Deacon, & Abramowitz, 2009; Feeny, Hembree, & Zoellner, 2004), that manualized treatments are not flexible enough to be effective ( Addis & Krasnow, 2000) among several other concerns (Deacon & Farrell, 2013) This negative bias towards exposure based techniques has been associated with suboptimal delivery (Deacon et al., 2013; Farrell, Deacon, Kemp, Dixon, & Sy, 2013; Harned et al., 2013). Little is known about how these negative attitudes and beliefs about exposure impact how often expo sure based techniques are utilized. In summary, the dissemination of CBT ET for anxiety disorders is historically poor and research is needed to better understand t he extent to which CBT ET is u sed by community providers to treat pedia tric anxiety disorde rs and the factors that underlie poor utilization To date, u tilization rates and predictors of utilization have never been reported in a sample of community providers who treat pediatric anxiety disorders. The purpose of this study is twofold: 1) to ident ify how frequently community practitioners who treat pediatric anxiety disorders utilize TAIVE and 2) to test the relative contributions of several potential factors that may be barriers to utilization and thus limit community dissemination. This study wil l b uild upon the previous research in this area and will represent an important step forward in the literature. Considering the chronic course of untreated anxiety in children and adolescents ( Keller et al., 1992; Perkonigg et al., 2014; Pine et al., 1998; Rapee et al., 2009) and the importanc e of early intervention (Rapee et al., 2009), it is crucial for a study of this nature to be conducted. Previous r esearch on treatment u tilization patterns has focused on utilization in specific state s such as

PAGE 17

17 Minnesota (Freiheit et al., 2004) and Wyoming (Hipol & Deacon, 2013), therefore a national examination of the United States is warranted. This study will build on a similar measure as previous research in this area that measured treatment utiliza tion (Freiheit et al., 2004; Hipol & Deacon, 2013) but will assess utilization specific to pediatric psychopathology and will also include popular methods including third wave cognitive behavioral therapy (Hayes, Luoma, Bond, Masuda & Lillis, 2006) Study Aims Aim 1. To quantify the utilization of TAIVE for pediatric anxiety disorders among a sample of 302 community providers. Hypothesis 1: TAIVE will be the least utilized exposure t echnique with the exception of trauma focused narrative for OCD, PD, and SAD. Hypothesis 2: TAIVE will be used less often t han non exposure cognitive behavioral techniques Hypothesis 3: TAIVE will be used more often than third wave cognitive behavioral techniques Hypothesis 4: TAIVE will be used more of ten than the non cognitive behavioral techniques Aim 2 To identify if practitioner demographics temperament, and negative attitudes and belief s about exposure based techniques are uniquely predictive of TAIVE utilization among a sample of 302 community providers Hy pothesis 1: Provider s who are fe male, work in a profession requiring a masters or equivalent and have less training in exposure based techniques will report less TAIVE utilization Hypothesis 2: Providers who have higher disgust and anxiety sensitivity will report less TAIVE utilization. Hypothesis 3: Providers who have more negative attitudes and beliefs about ex posure treatments will report less TAIVE utilization.

PAGE 18

18 CHAPTER 2 METHODS Participants This study was approved by the lo cal Institutional Review Board and sought to recruit a sample of community based practitioners who treat pediatric anxiety disorders In an effort to recruit a diverse and nationally representative sample, e mail and phone recruitment was utilized Practit ioners who listed their contact information on publically accessible online psychology/mental health directories (e.g. state specific psychological association directories, state specific mental health counselor directories) were contacted Whenever possible, filters were used to only identify practitioners who treat children and adolescents with anxiety disorders. Contact information in the form of e mail addresses or phone numbers for licensed psychologists, counselors, clinical social workers, psyc hiatrists, and psychiatric nurses w ere collected from each search engine within every zip code of the United States. An e mail management system was used to manage email recruitment. These recruitment methods resulted in attempted c ontact by phone or emai l for 8584 practitioners over a 16 month time frame. Due to our inability to directly assess who saw the e mail or listened to the voicemail made during phone contacts, it is impossible to estimate how many practitioners heard about the study. Out of 482 pr actitioners who read the electronic consent 302 practitioners consented and completed at least the demographics form Our final sample (N = 302) was approximately equal to the 2010 Census population distribution per region of the United States ( Mackun & W ilson, 2011 ). Specifically 18 % of ou r sample was from region 1 (18 % of 2010 Ce nsus), 18 % from region 2 (22% of 2010 Census), 37 % from region 3 (37 % of 2010 Census), and 2 7% from region 4 ( 23 % of 2010 Census).

PAGE 19

19 Inclusionary criteria required that practitioners be licensed as a mental health specialist and have treated at least one child or adolescent (ages 7 17) with a diagnosis of OCD, PTSD, PD, or SAD in the last year. The average age of the sample was 49.84 ye ars (SD = 11.77 ). Participants self i dentified as psychologists ( 46 % ), clinical social workers ( 28 %), counselors ( 21 %), nurse practitioners ( 3 %), or listed other professions such as marriage and family therapists, psychiatrists play t herapi sts, or art therapist ( 2 % combined). The sample largely identified as Caucasian (90%) females (74 %) who work in private practice (90 %) Over a third of the sample self identified as pediatric anxiety specialists (39%) and reported receiving clinical traini ng in an academically affiliated anxiety disorder clinic (39%) Respondents had been treating children or adolescents with anxiety disorders for an average of 16.26 years (SD = 10.26). Of our final sample, 200 practitioners reported treating at least one p atient with OCD in the last year (M = 6.69, SD = 8.75) 197 reported treating at least one patient with PTSD in the last year (M = 8.32, SD = 8.95) 165 reported treating at least one patient with PD in the last year (M = 5.56, SD = 8.55) and 199 reported treating at least one patient with SAD in the last year (M = 8.65, SD = 8.30) Procedure Whether participants were contacted by email or phone, they responded to an online survey. The survey was created and managed using a secure university contracted sur vey provider. Every participant received three e mails over the course of several months if they had not clicked on the link to the survey Only those without listed e mails were called once and a voicemail was left if they did not respond. Recruitment was conducted over the course of sixteen months An online consent was utilized that required participants to electronically consent before they could proceed to the surveys. The demographics survey was presented first, followed by surveys asking about utiliz ation of various treatment techniques for OCD, PTSD, PD, and SAD.

PAGE 20

20 Finally, temperament measures and exposure specific surveys were presented. Participants could not go back and change any previous answers. Measures Utilization Rates for Exposure based Tech niques Participants were asked about their utilization of thirty therapeutic techniques. This list of tre atments was based off similar surveys used by Hipol and Deacon (2013) and Fr e i heit and colleagues (2004). The list of treatments was adapted for pract itioners who treat pediatric anxiety disorders (e.g., play therapy was added) and updated to capture specific third wave cognitive The measure began by asking about utilization rates for the treatment of pediatric OCD in the last 12 months A screening question probed if the practitioner had treated at least one pediatric (7 17 year old) OCD case in the last year. If they responded y es to this question t hey were asked frequently did you utilize the following techniques to treat pediatric OCD (0 and provided u tilization rates for the thirty treatment techniques These techniques included expo sure based techniques (central to empirically supported treatment), non exposure cognitive behavioral techniques ( techniques such as breathing retraining and cognitive restructuring that are less central to empirically supported treatment) so called thir d wave cognitive behavioral techniques (recently developed techniques such as acceptance and mindfulness that currently have minimal empirical support for use with youth ; Hayes et al., 2006) and several non cognitive behavioral techniques ( older techniqu es with minimal empirical support for use with youth such as psychodynamic therapy ) that are often marketed to community practitioners This data collection process was repeated for PTSD, PD, and SAD. The specific techniques polled can be found in Table 1.

PAGE 21

21 Training in Exposure based Techniques The Exp osure Training Assessment ( Guzick et al., 2015 ) is a 15 item measure that assess es previous training experience in exposure based techniques The self report measure evaluates how frequently practitioners received exposure specific training across a number of modalities (e.g., workshops, at a general clinic, academic classes) using a nine point Likert scale (1 = never received training in that modality, 9 = always received training in that modality). The Ex posure Training Assessment has acceptable psychometrics and yields a four factor structure that captures general graduate school, online education, general post graduate training, and specialty training in exposure based treatment techniques. These four fa ctors combine to create a total score that was used in this study. Disgust Sensitivity The Disgust Scale (Haidt, McCauley, & Rozin, 1994) was used to measure disgust sensitivity, which is the predisposition to experience disgust in response to a wide array of aversive stimuli or situations The Disgust Scale is a 32 item measure that captures eight domains of disgust sensitivity: food, animals, body products, body envelope violations, death, sex, hygiene and sympathetic magic. Psychometric research suggests that these items are best represented by a three factor solution (Core Disgust, Animal Reminder Disgust, Contamination Based Disgust) comprised of 27 items that can be combined to create a total disgust sc ore (Olatunji et al., 2007). 0.7 9 Anxiety Sensitivity The Anxiety Sensitivity Index 3 (Taylor et al., 2007) is a measure that captures anxiety sensitivity, which is fear about the consequences of physical and cognitive indications of anxious arousal The Anxiety Sensitivity Index 3 yields a total score that has good psychometrics in

PAGE 22

22 clinical and non clinical samples and is broadly associated with various anxiety condition s (Taylor et al., 2007; Wheaton, Deacon McGrath, Berman, & Abramowitz, 2012). Previous research has suggested that a lower total score is predictive of clinical proficiency in exposure based techniques ( Harned et al., 2013 ). score was 0 80 Negative Attitudes and Beliefs The Therapists Beliefs about Exposure Scale is a 21 item, self report measure of negative attitudes and beliefs towards exposure based techniques (e.g., that it is intolerable, unethical, and harmful; Deacon et al., 2013). Each negative attitude and belief is scored on a 5 point Likert single factor stru cture with strong psychometric properties (Deacon et al., 2013). Higher scores reflect stronger negative attitudes and beliefs about exposure based techniques for this total score was 0.93 Statistical Analyses For aim one means and stan dard deviations for all treatment techniques listed are reported for OCD, PTSD, PD, and SAD. Descriptive statistics were run on all study independent and dependent variables. Any variables displaying notable skewness and/or kurtosis were Blom transformed ( Blom, 1954). All variables were then standardized to allow for direct comparison. Tests were conducted for multico l linearity and a residualization procedure was conducted to make the variables orthogonal. was conducted to test for significant patterns of missing data. For aim two four hierarchal linea r regression s were implemented Each hierarchal linear regression had TAIVE for OCD, PTSD, PD, or SAD as the dependent variable. All four regressions had the sam e independent variables entered in the same order Block one contained demographic related independen t variables of interest, block two contain ed all temperament

PAGE 23

23 related independent variables of interest and block three contain ed one variable related to p ractitioners negative attitudes and beliefs about exposure based techniques For the aim two analyses gender was coded as a dichotomous variable (0 = male; 1 = f emale). Similarly a dichotomous variable was create d to represent participants self reported profession (0 = p rofessions requiring one to two ye ars of graduate education; 1 = p rofessions requiring more than two years of graduate education) a nd anxiety specialization (0 = non specialist; 1 = s pecialist). The total scores from the Exposure Training Assessment (i.e., exposure specific training ), Anxiety Sensitivity Index 3 (i.e., anxiety sensitivity) Disgust Scale (i.e., disgust sensitivity) and Therapist Beliefs About Exposure Scale (i.e., negative attitudes and beliefs about exposure) wer e all entered as continuous variables where higher scores represent more training in exposure based techniques higher anxiety and disgust sensitivity, and more negative attitudes and beliefs about exposure based techniques respectively.

PAGE 24

24 CHAPTER 3 RESUL TS Aim 1. Treatment Utilization Patterns Practitioners provide d information about the frequency they used various treatment techniques to treat pediatric OCD, PTSD, PD, and SAD. These treatment utilization patterns are displayed in Table 3 1. To improve interpretability of these findings, treatment techniques were categorized in to four groups: non exposure cognitive behavioral techniques, exposure techniques, third wave cognitive behavioral techniques, and non cognitive behavioral techniques. Within expo sure techniques, TAIVE was consistently used less than client self directed in vivo exposure and imaginal exposure across all four anxiety disorders studied. Therapist assisted in vivo exposure was used most frequently for OCD and least frequently for PTSD Trauma focused narrative was used more often than TAIVE for PTSD. Interoceptive exposure was used less than TAIVE and every other exposure based technique for PD. Not including behavioral therapy, TAIVE was utilized less than every non exposure cognitiv e behavioral technique l isted across all four disorders. This includes techniques such as cognitive restructuring, which was consistently used more than any of the thirty technique s listed (except mindfulness for PTSD). This also includes arousal reduction strategies such as breathing retraining and progressive muscle relaxation. In terms of third wave behavioral techniques, TAIVE was used more than cognitive diffusion, value based committed action and self as context across all four anxiety disorders. On the other hand, mindfulness was consistently used more than TAIVE across all four disorders. There was no consistent pattern in the use of TAIVE compared to acceptance, meditation, and motivational interviewing across the four anxiety disorders. For examp le, TAIVE was used more

PAGE 25

25 often than meditation and motivational interviewing for OCD, but the opposite pattern was observed for the treatment of pediatric PTSD. Therapist assisted in vivo exposure was generally used more than several non cognitive behaviora l techniques across the four anxiety disorders (e.g., thought field therapy). However, some disorder dependent differences were observed For example, art therapy and gestalt therapy were used less than TAIVE for OCD, PD, and SAD but more than TAIVE for P TSD F amily systems therapy and non directive supporting psychotherapy were used more often than TAIVE for PTSD, PD, and SAD but not OCD For PTSD, eye movement desensitization and reprocessing was used more commonly than TAIVE. Aim 2 Predictors of Therapist Assisted E xposure b ased Technique Use Preliminary Analyses Missing data was examined for all ind ependent or dependent variables Missing data was for the subsample s of practitioners who treat OCD ( p = .34), PTSD ( p = .19), PD ( p = .47), and SAD ( p = .23). After list wise deletio n, our final subsamples for analyses were 143 practitioners who treat ed pediatric OCD, 1 34 who treated pediatric PTSD 144 who treated PD, a nd 146 who treated SAD To investigate the independent associations between the independent variables of interest and TAIVE use, bivariate correlations were first conducted. Th e bivariate correlations among the study independent variables can be observed in Table 3 2 Notably, more negative attitudes and beliefs about exposure based techniques was associated with being female ( r (242) = .20, p = .007 ), having a profession requiring one to two years of graduate education ( r (230) = .39, p < .001 ), categoriz ing oneself as a non anxiety specialist ( r (241) = .28, p < .001 ), more training in exposure based techniques ( r (216) = .37, p < .001), higher anxiety sensitivity ( r (222) = .30, p < .001 ), and higher disgust sensitivity ( r (218) = .23, p < .001 ). The bivariate correlations between

PAGE 26

26 these independent variables and TAIVE for OCD, PTSD, PD, and SAD can be observed in Table 3 3 Gender and disgust sensitivity w ere not significantly associated with TAIVE use for any of the four anxiety disorders (all p s > 31) Having more anxiety sensitivity was weakly associated with TAIVE for OCD, PTSD, and SAD (all p s < .08 ) Identifying as an anxiety specialist, having more training in exposure based techniques and endorsing less negative attitudes and beliefs about ex posure based techniques w ere significantly associated with more TAIVE use across all four disorders (all p s < .05) Linear Regression Analyses Results for the hierarchal linear regression analyses investigating how the independent variables of interest are associated with TAIVE for pediatric OCD, PTSD, PD, and SAD can be observed in Table s 3 4 through 3 7 For all four models described below, all assumptions of the General Linear Model were met and no notable mu lt icollinearity was observed ( t olerance was below 0. 10 for all study variables ). Therapist Assisted In Vivo Exposure Use for Pediatric Obsessive Compulsive Disorder Step 1 of the linear regression (practitioner demographics) explained 26 % of the variance in TAIVE for OCD and resulted in a significant change in the F statistic ( 11.30, p < .001) P ractitioner gender ( 0.01, p = .90) and profession (0.06, p = .49) w ere not associated with TAIVE for OCD However, self identifying as a specialist (0.31, p < .001) and having more training in exposure based techniques (0.29, p < .001) were both significantly associated with more TAIVE use for OCD. Self identifying as an anxiety disorder specialist (rather than a non specialist) was associated with a 0 .29 stand ard deviation increase in TAIVE use for OCD. Step 2 of the linear regression (practitioner temperament) explained only an additional 1 % of the variance in TAIVE for OCD beyond what w as explained by step 1 and did not result in a significant improvement i n the F statistic ( 0.60, p = .55) Neither disgust sensitivity (0.05, p

PAGE 27

27 = .62) nor anxiety sensitivity ( 0.10, p = .28) were significantly associated with TAIVE in this step. This step did not change the pattern of significance observed in the demographic variables of interest entered during step 1. Step 3 of the linear regression (practitioner attitudes and beliefs) explained an additional 21 % of the variance in TAIVE for OCD from step 2 and resulted in a significant improvement in the F statistic ( 49.90, p < .001) Negative attitudes and beliefs was significantly associated with TAIVE use for OCD (0.57, p < .001) ; a one standard deviation increase in negative attitudes and beliefs was associated with a 0.57 standard deviation reduction in TAIVE use for OCD. B oth specialization (0.18, p = .01) and training in exposure based techniques (0.15, p = .04) remained significantly associated with TAIVE for OCD, although the strength of their associations weakened. Therapist Assisted In Vivo Exposure Use for Pediatric Post Traumatic Stress Disorder Step 1 of the linear regression (practitioner demographics) explained 12 % of the variance in TAIVE for PTSD and resulted in a significant change in the F statistic ( 4.57, p = .002 ) P ractitioner gender ( 0.12, p = .21 ) and profession ( 0.03, p = .79) w ere not significantly associated with TAIVE for PTSD However, self identifying as a specialist (0.22, p = .02 ) and having more training in exposure based techniques (0.21, p = .02 ) were both significantly associated w ith more TAIVE use for PTSD Self identifying as an anxiety disorder specialist (rather than a non specialist) was associated with a 0 .2 2 standard deviation increase in TAIVE use for PTSD Step 2 of the linear regression (practitioner temperament) explai ned only an additional 1% of the variance in TAIVE for PTSD beyond what was explained by step 1 and did not result in a significant improvement in the F statistic ( 0.52, p = 60) Neither disgust sensitivity ( 0.05, p

PAGE 28

28 = .65 ) n or anxiety sensitivity ( 0.07, p = .51 ) were significantly associated with TAIVE in this step. This step did not change the pattern of significance observed in the demographic variables of interest entered during step 1. Step 3 of the linear regression ( practitioner attitudes and beliefs) explained an additional 3 % of the variance in TAIVE for OCD from step 2 and resulted in a significant improvement in the F statistic ( 4.59, p = .03) Negative attitudes and beliefs was significantly a ssociated with TAIVE use for PTSD ( 0.24, p = .03 ) ; a one standard deviation increase in negative attitudes and beliefs was associated with a 0. 24 standard deviation reduction in TAIVE use for PTSD Training in exposure based techniques was no longer significantly associated with TAIVE for PTSD in step 3 (0.15, p = .11 ) The association between being a specialist and TAIVE use for PTSD was only trending towards significance in step 3 (0.18, p = .05 ) Therapist Assisted In Vivo Exposure Use for Pediatric Panic Disorder Step 1 of the linear regression (practitioner demographics) explained 17 % of the variance in TAIVE for PD and resulted in a significant change in the F statistic ( 6.40, p < .001) P ractitioner gender (0.03, p =.69) and self identification as a specialist (0.13 p = .16) w ere not associated with TAIVE for P D. Furthermore, having a profession requiring more than two years of graduate school was on ly weakly associated with more TAIVE for PD (0.17, p = .07) H aving more training in exposure based techniques was significantly associated with more TAIVE use for PD (0.26, p < .001) A one standard deviation increase in the amount of training in exposure based techniques was associated with a 0 .2 6 standard deviation increase in TAIVE use for PD Step 2 of the line ar regression (practitioner temperament) explained less than 1% of the variance in TAIVE for P D beyond what was explained by step 1 and did not result in a significant improvement in the F statistic ( 0.12, p = .89) Neither disgust sensitivity (0.02, p =

PAGE 29

29 87) nor anxiety sensitivity ( 0.05, p = .62) were significantly associated with TAIVE for PD in this step. This step did not change the pattern of significance observed in the demographic variables of interest entered during step 1. Step 3 of the linear regression (practitioner attitudes and beliefs) explained an additional 2 2 % of the variance in TAIVE for OCD from step 2 and resulted in a significant improvement in the F statistic ( 44.92, p < .001) Negative attitudes and beliefs was strongly associated with TAIVE use for PD (0.57, p < .001) ; a one standard deviation increase in negative attitudes and beliefs was associated with a 0.57 standard deviation reduction in TAIVE use for P D. B oth profession (0.03, p = .72) and training in exposure based techniques (0.13, p = .11) were no longer significantly associated with TAIVE for PD. Therapist Assisted In Vivo Exposure Use for Pediatric Social Anxiety Disorder Step 1 of the linear regression (practitione r demographics) explained 1 6% of the variance in TAIVE for SAD and resulted in a significant change in the F statistic ( 7.00, p < .001) P ractitioner gender ( 0.03, p = .70) and profession (0.06, p = .49) w ere not associated with TAIVE for SAD However, self identifying as a specialist (0.20, p = .02) and having more training in exposure based techniques (0.26, p = .002) were both significantly associated with more TAIVE use for SAD A one standard deviation increase in the amount of training in exposure based techniques was associated with a 0 .2 6 standard deviation increase in TAIVE use for SAD Step 2 of the linear regression (practitioner temperament) explained only an additional 1% of the variance in TAIVE for SAD beyond what was explained b y step 1 and did not result in a significant improvement in the F statistic (1.03, p = .36) Neither disgust sensitivity ( 0.09, p = .28 ) nor anxiety sensitivity ( .12, p = .20 ) were significantly associated with TAIVE in this step.

PAGE 30

30 This step did not change the pattern of significance observed in the demographic variables of interest entered during step 1. Step 3 of the linear regression (practitioner attitudes and beliefs) explained an additional 17 % of the variance in TAIVE for SA D from step 2 and resulted in a significant improvement in the F statistic (36.13, p < .001) Negative attitudes and beliefs w ere significantly associated with TAIVE use for SA D (0.52, p < .001) ; a one standard deviation increase in negative attitudes and beliefs was associated with a 0.5 2 standard deviation reduction in TAIVE use for SA D. Both training in exposure based techniques remained significantly associated (0.16, p = .04) although self identifying as an anxiety disorder specialist was no longer si gnificantly associated with TAIVE for SAD (0.10, p = .18)

PAGE 31

31 Table 3 1. Treatment utilization patterns for pediatric anxiety disorders Technique Frequency % (SD) OCD ( n = 200) PTSD ( n = 197) PD ( n = 165) SAD ( n = 199) Non exposure CBT techniques Cognitive Restructuring 55.45 (34.3 2 ) 50.89 (35.4 0 ) 63.6 2 (34.2 5 ) 65. 64 (31. 6 7) Breathing Retraining 49.1 1 (36.07 ) 52.05 (36.3 1 ) 64.65 (35.9 4 ) 51.97 (37.7 1 ) Progressive Muscle Relaxation 44.87 (35.65 ) 46.45 (36.66 ) 55.9 1 (36.1 0 ) 46.95 (36.6 2 ) Elimination of Avoidance/ Safety Seeking Behaviors 50.98 (38.19 ) 35.5 3 (33.45 ) 51.6 4 (36.59 ) 52.76 (37.1 4 ) Thought Stopping Techniques 37.55 (37.3 2 ) 33.76 (34.58 ) 36.47 (37.3 0 ) 30.37 (35.17 ) Elimination of Family Accommodation 33.8 4 (38.4 4 ) 12. 89 (26.58 ) 22.3 1 (32.37 ) 26.9 2 (35.7 5 ) Exposure techniques Therapist Assisted In Vivo Exposure 30.6 1 (36.8 2 ) 11.57 (24.0 4 ) 21.06 (30.29 ) 22.0 1 (34.4 1 ) Client Self Directed In Vivo Exposure 36.6 0 (37.56 ) 18.0 1 (27.48 ) 37.75 (36.3 2 ) 36.88 (38.28 ) Imaginal Exposure 40.7 1 (32.8 0 ) 31.9 0 (33.6 3 ) 41.89 (35.2 9 ) 41.27 (35.1 3 ) Trauma Focused Narrative 12.8 3 (22.6 3 ) 37.0 0 (36.37 ) 14.19 (26.89 ) 9.5 1 (23.4 1 ) Interoceptive Exposure 5.58 (16.3 1 ) 4.2 2 (14.4 1 ) 11.07 (27.97 ) 4.8 1 (17.3 1 ) Third wave techniques Mindfulness Techniques 47.98 (35.36 ) 54.6 4 (34.7 1 ) 58.65 (35. 0 0) 51.68 (35.3 1 ) Acceptance 31.0 4 (35.56 ) 30.98 (35.57 ) 27.8 5 (36.68 ) 27.26 (36.0 3 ) Meditation 26.5 0 (32.0 4 ) 28.6 2 (32.2 2 ) 31.67 (37.1 2 ) 23. 27 (32.7 5 ) Motivational interview Dialectical Behavioral Therapy 23.0 3 (32.5 1 ) 14.04 (24.20) 19.06 (30.18 ) 15.11 (26.70) 21.07 (33.46 ) 12.27 (26.20) 26.0 3 (35.5 0 ) 11.10 (25.54) Cognitive Diffusion 9.08 (22.76 ) 9.15 (22.17 ) 9.3 2 (23.2 5 ) 10.89 (25.17 ) Value based Committed Action 6.57 (19.5 4 ) 8.18 (22.07 ) 8.05 (23.3 7 ) 11.7 4 (27. 7 8) Self as context 3.8 4 (14.6 4 ) 7.6 3 (21.59 ) 6.7 3 (20.67 ) 5.28 (19.2 3 ) Note: CBT= cognitive behavioral therapy, EMDR= eye movement desensitization and r eprocessing, OCD= obsessive compulsive disorder, PTSD= p ost traumatic stress disorder, PD= panic disorder, SAD= social anxiety d isorder

PAGE 32

32 Table 3 1. Continued. Technique Frequency % (SD) OCD ( n = 200) PTSD ( n = 197) PD ( n = 165) SAD ( n = 199) Non Directive Supportive Psychotherapy 23.08 (30.1 3 ) 32.88 (33.58 ) 27.67 (32.93) 31.38 (34.17 ) Play Therapy 18.79 (29.1 3 ) 31.97 (35.6 4 ) 20.47 (31.86 ) 20.4 2 (31.9 2 ) Interpersonal Therapy 17.77 (28.3 5 ) 21.28 (32.1 0 ) 17.98 (30.6 1 ) 21.1 4 (31.87 ) Art Therapy 14.66 (25.19 ) 24.55 (32.29 ) 15.7 1 (29.36 ) 14.77 (27.6 1 ) Psychodynamic Therapy 12.0 1 (24.69 ) 16.49 (28.27 ) 15.48 (28.4 5 ) 13.98 (27.36 ) Hypnosis 4.96 (17.0 0 ) 6.1 3 (20.6 1 ) 8.79 (24.4 2 ) 6.7 4 (22.18 ) Applied Behavior al Analysis 5.16 (14.86 ) 6.09 (19.2 1 ) 6.66 (20.5 2 ) 6.6 1 (19.9 2 ) Gestalt Therapy 2.59 (11.2 6 ) 4.6 3 (13.8 1 ) 5.2 5 (18.2 4 ) 3.88 (15.25 ) Thought Field Therapy Family Systems Therapy 0.98 (6.78 ) 28.93 (31.84) 1.8 0 (8.9 3 ) 34.60 (33.60) 1. 67 (9.97 ) 30.16 (34.52) 1.09 (8.58 ) 28.05 (33.32) Note: CBT= cognitive behavioral therapy, EMDR= eye movement desensitization and reprocessing, OCD= o bsess ive compulsive disorder, PTSD= p ost traumatic stress disorder, PD= panic disorder, SAD= s oc ial anxiety d isorder.

PAGE 33

33 Table 3 2. Correlations among independent variables Gender Profession Specialist ETA ASI 3 DS TBES Gender a Profession b .22 *** Specialist c .07 .12 ETA d .01 .27 ** .28 *** ASI 3 e .08 .01 .14 .28 *** DS f .18 ** .15* .01 .21 ** .36 *** TBES g .20 ** .39 *** .28 *** .37 *** .30 *** .12 Note: a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate education ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report measure of training in exposure based techniques during and/or after graduate school; e Continuous self report measure of anxiety sensitivity; f Continuous self report measure of disgust sensitivity; g Continuous self report measure of practitioner negative attitudes and beliefs about exposure based techniques. Significance is represented as follows: p < .05*, p < .01**, p < .001***

PAGE 34

34 Table 3 3 Correlations of study independent and dependent variables TAIVE for OCD TAIVE for PTSD TAIVE for PD TAIVE for SAD Gender a Profession b .02 .28 *** .07 .16 .04 .30 ** .03 .23 ** Specialist c .35 *** .21 ** .21 ** .24 ** ETA d .35 *** .27 ** .34 *** .33 *** ASI 3 e .15 + .1 4 + 13 .15 + DS f .03 08 .12 .04 TBES g 65 *** .30 *** .58 *** .56 *** Note: a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate education ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report mea sure of training in exposure based techniques during and/or after graduate school; e Continuous self report measure of anxiety sensitivity; f Continuous self report measure of disgust sensitivity; g Continuous self report measure of practitioner negative atti tudes and beliefs about exposure based techniques. Significance is represented as follows: p < .05*, p < .01**, p < .001***

PAGE 35

35 Table 3 4 Predictors of therapist ass isted in vivo exposure for OCD Beta 95% CI R 2 Change R 2 Change F Step 1. Demographics Gender a Profession b Specialist c ETA d Step 2. Temperament Gender Profession Specialist ETA DS e ASI 3 f Step 3. Attitudes and Beliefs Gender Profession Specialist ETA DS ASI 3 TBES g 0.01 (0.08) 0.06 (0.09) 0.31 (0.08 ) *** 0.29 ( 0 .08) *** 0.02 (0.08) 0.07 (0.09) 0.31 (0.08) *** 0.27 (0.08) *** 0.05 (0.09) 0.10 (0.09) 0.07 (0.07) 0.05 (0.08) 0.18 (0.07) 0.15 (0.07) 0.00 (0.08) 0.06 (0.08) 0.57 (0.08) *** ( 0.17, 0.15) ( 0.12., 0.23) (0.15, 0.47) (0.13, 0.44) ( 0.18, 0.15) ( 0.10, 0.24) (0.15, 0.46) (0.10, 0.43) ( 0.14, 0.23) ( 0.28, 0.08) ( 0.07, 0.21) ( 0.20, 0.11 ) (0.04, 0.31) (0.01, 0.30) ( 0.16, 0.16) ( 0.10, 0.21) ( 0.73, 0.41) .259 .266 .475 .259 .007 .208 11.30 *** 0.60 49.90 *** Note: Only participants with complete data were inclu ded for this analysis (N = 143) a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate educ ation ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report measure of training in exposure based techniques during and/or after graduate school; e Continuous self report measure of disgust sensitivity ; f Continuous self report measure of anxiety sensitivity ; g Continuous self report measure of practitioner negative attitudes and beliefs about exposure based techniques. Significance is represented as follows: p < .05*, p < .01**, p < .001***

PAGE 36

36 Table 3 5 Predictors of therapist assisted in vivo exposure for PTSD Beta 95% CI R 2 Change R 2 Change F Step 1. Demographics Gender a Profession b Specialist c ETA d Step 2. Temperament Gender Profession Specialist ETA DS e ASI 3 f Step 3. Attitudes and Beliefs Gender Profession Specialist ETA DS ASI 3 TBES g 0.12 (0.09 ) 0.03 (0.09) 0. 22 (0.09 ) 0.21 ( 0 .08) 0.11 (0.10) 0.03 (0.10) 0.22 (0.09) 0.19 (0.09) 0. 05 (0.10 ) 0. 07 (0.10 ) 0.08 (0.10) 0.08 (0.10) 0.18 (0.09) + 0.15 (0.09) 0.09 (0.10) 0.02 (0.11) 0.24 ( 0.11 ) ( 0.31, 0.07 ) ( 0.21 0.16 ) ( 0.04, 0.40 ) (0.04, 0.38 ) ( 0.30, 0.08) ( 0.22, 0.16) (0.04, 0.40) (0.12, 0.37) ( 0. 25, 0.16 ) ( 0.27, 0.13 ) ( 0.27, 0.11) ( 0.27, 0.11) (0.00, 0.36) ( 0.03, 0.33) ( 0.30, 0.12) ( 0.20, 0.23) ( 0.46, 0.02 ) .123 130 161 .123 .007 030 4 .57 ** 0.52 4.59 Note: Only participants with complete data were included for this analysis (N = 1 3 4) a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate education ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report measure of trai ning in exposure based techniques during and/or after graduate school; e Continuous self report measure of disgust sensitivity; f Continuous self report measure of anxiety sensitivity ; g Continuous self report measure of practitioner negative attitudes and be liefs about exposure based techniques. Significance is represented as follows: p < .05*, p < .01**, p < .001***

PAGE 37

37 Table 3 6 Predictors of therapist assisted in vivo exposure for PD Beta 95% CI R 2 Change R 2 Change F Step 1. Demographics Gender a Profession b Specialist c ETA d Step 2. Temperament Gender Profession Specialist ETA DS e ASI 3 f Step 3. Attitudes and Beliefs Gender Profession Specialist ETA DS ASI 3 TBES g 0.03 (0.09 ) 0.1 7 (0.09) + 0.13 (0.09) 0.26 (.09 ) *** 0.03 (0.09) 0.18 (0.09) + 0.13 (0.09) 0.25 (0.09) ** 0.02 (0.09) 0.05 (0.10 ) 0.10 (0.08) 0.03 (0.08) 0.06 (0.08) 0.13 (0.08) 0.02 (0.08) 0.12 (0.09) 0.57 (0.08) *** ( 0.13, 0.20 ) ( 0.01., 0.35 ) ( 0.05, 0.30 ) (0.09, 0.43 ) ( 0.15, 0.20) ( 0.01, 0.36) ( 0.05, 0.30) (0.07, 0.43) ( 0.18, 0.21 ) ( 0.25, 0.15 ) ( 0.05, 0.25) ( 0.14, 0.19) ( 0.09, 0.21) ( 0.03, 0.29) ( 0.18, 0.15) ( 0.06, 0.30) ( 0.77, 0.42 ) 171 .173 .397 .171 .002 .224 6.4 0 *** 0.01 44.92 *** Note: Only participants with complete data were included for this analysis (N = 144) a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate education ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report measure of training in exposure based techniques during and/or after graduate school; e Continu ous self report measure of disgust sensitivity; f Continuous self report measure of anxiety sensitivity ; g Continuous self report measure of practitioner negative attitudes and beliefs about exposure based techniques. Significance is represented as follows : p < .05*, p < .01**, p < .001***

PAGE 38

38 Table 3 7 Predictors of therapist assisted in vivo exposure for SAD Beta 95% CI R 2 Change R 2 Change F Step 1. Demographics Gender a Profession b Specialist c ETA d Step 2. Temperament Gender Profession Specialist ETA DS e ASI 3 f Step 3. Attitudes and Beliefs Gender Profession Specialist ETA DS ASI 3 TBES g 0.03 (0.08) 0.06 (0.09) 0.20 (0.08 ) 0.26 ( 0 .08) ** 0.05 (0.08) 0.08 (0.09) 0.18 (0.08) 0.25 (0.09) ** 0.09 (0.09) 0.12 (0.09) 0.01 (0.07) 0.07 (0.08) 0.10 (0.07) 0.16 (0.08) 0.05 (0.08) 0.06 (0.09) 0.52 (0.09 ) *** ( 0.19, 0.13) ( 0.11., 0.23) (0.04, 0.35) (0.10, 0.42) ( 0.21, 0.11) ( 0.09, 0.26) (0.02, 0.34) (0.08, 0.42) ( 0.08, 0.26) ( 0.29, 0.06) ( 0.15, 0.14) ( 0.23, 0.10) ( 0.05, 0.25) (0.01, 0.31) ( 0.11, 0.20) ( 0.11, 0.22) ( 0.69, 0.35) .161 .173 .340 .161 .012 .167 7.00 *** 1.03 36.13 *** Note: Only participants with complete data were included for this analysis (N = 14 6 ) a reported gender (0 = Male, 1 = Female); b reported profession categorized into two groups ( 0 = Professions requiring one to two years of graduate education; 1 = Professions requiring more than two years of graduate education ); c Participants self reported if they viewed themselves as an anxiety disorder specialist (0 = Non specialist, 1 = Specialist); d Continuous self report measure of training in exposure based techniques during and/or after graduate school; e Continuous self repo rt measure of disgust sensitivity; f Continuous self report measure of anxiety sensitivity ; g Continuous self report measure of practitioner negative attitudes and beliefs about exposure based techniques. Significance is represented as follows: p < .05*, p < .01**, p < .001***

PAGE 39

39 CHAPTER 4 DISCUSSION Results of this study suggest that community practitioners who treat pediatric anxiety disorders generally do not use exposure based techniques, which are a key ingredient for the successful treatment of pediatric anxiety disorders ( Abramowitz et al. 2010; Lohr et al., 2012 ) The exposure technique most consistent with behavioral principals and efficacious in children and adolescents (Abramowitz, 1996; Abramowitz et al., 2002; Armfield, 2008; st et al., 1997; Ultee et al., 1982) TAIVE was used only 31 % of the time by community practitioners who treat pediatric OCD, 12% of the time by community practitioners who treat pediatric PTSD 21% of the time by community practitioners who treat pediatric PD and 22% of the time by community practitioners who treat pediatric SAD As hypothesized, TAIVE was used less than most non exposure cognitive behavioral techniques (e.g., cognitive restructuring) TAIVE was used more than most techn iques outside of cognitive behavioral therapy (e.g., psychodynamic therapy thought field therapy ). Results were mixed for the differences between TAIVE and third wave cognitive behavioral techniques Taken as a whole, these treatment utilization patterns generally match those of community practitioners who treat adult anxiety disorders ( Freiheit et al., 2004; Hipol & Deacon, 2013) and suggest that most community practitioners who treat anxiety disorders use a form of cognitive behavioral therapy heavy on n on exposure techniques or third wave techniques and light on TAIVE. This supports a previously proposed idea that exposure based techniques are vie wed by community providers as a tool rather than the central active ingredient of anxiety disorder treatment (Hipol & Deacon, 2013). investigate multiple theoretically or empirically supported barriers to dissemination of exposure based techniques for pediatric OCD, PTSD, PD, and SAD. In general practitio ners who

PAGE 40

40 identified as an anxiety disorder specialist and acquired more exposure specific training throughout their education and career were more likely to utilize TAIVE. While the bivariate correlation of profession type and TAIVE was significant across all four disorders, it was not a significant predictor of TAIVE in any of the regression models. This suggests that the specificity of training in psychotherapy for pediatric anxiety disorders is vital; community practitioners need exposure specific traini ng if dissemination is to improve. Inconsistent with previous literature, our regression models did not provide any support for practitioner gender or temperament (i.e., anxiety and disgust sensitivity) as a barrier to the dissemination of TAIVE. On the ot her hand, attitudes and beliefs about exposure therapy was consistently the strongest predictor of TAIVE across the four anxiety disorders (e.g., attitudes and beliefs explained more variance in TAIVE than the demographic and temperament factors combined f or OCD, PD, and SAD). Echoing previous research (Freiheit et al., 2004; Hipol & Deacon, 2013) exposure based techniques are not o nly underutilized compared to other techniques but often less effective exposure based techniques are used more frequently t han more effective techniques For OCD and SAD at least imaginal exposures can be an effective add on to TAIVE ( Abramowitz, 1996 ) and can often represent a step towards in vivo exposure for reluctant patients or for patients with a feared stimulus that is difficult to simulate repeatedly (e.g., flying in an airplane) Similarly, client self directed in vivo exposure assigned as homework is an important part of CBT ET for pediatric anxiety disorders (Park et al., 2014 ). In our sample, TAIVE was used less th an imaginal exposure and client self directed in vivo exposure when the use of imaginal exposures and client self directed in vivo exposure should be notably lower than TAIVE ( Abramowitz, 1996; Abramowitz et al., 2002; Armfield, 2008; Foa, Yadin, & Lichner, 2012; Kendall & Hedtke, 2006; March & Mulle, 1998; st et al. 1997; Ultee, Griffioen, & Schellekens, 1982 ). For PD,

PAGE 41

41 both TAIVE and interoceptive exposure should be highly utilized ( Angelosante et al., 2009; Pincus et al. 2010 ) I n our sample TA IVE was again used less than imaginal exposure and client self directed in vivo exposure for PD More so, i nteroceptive exposure was only utilized 11% of the time to treat pediatric PD which means it was used less than any other exposure based technique li sted ( including trauma focused narrative ) for PD For PTSD, trauma focused narrative (e.g., describing traumatic experience), imaginal exposures (e.g., imaging experiencing traumatic event), and TAIVE (e.g., in vivo exposure to stimuli, activities, or envi ronments associated with traumatic event) should all be highly utilized ( Deblinger et al., 2011; Foa et al 2008; TF CBT Web, 2005 ). However in our sample, i maginal exposure and trauma focused narrative were both used more than twice as often as TAIVE for PTSD. E ven when community practitioners do use exposure therapy they generally choose other less invasive and less effective exposure based techniques over TAIVE. Th e underutilization of exposure based techniques especially TAIVE, is not only contradictory to research but could be argued as unethical. Practitioners have an ethical mandate to practice in a manner that is consistent with scientific and professional knowledge of the discipline and within their scope of expertise (Anderson, 2006). In this vein, s everal leading professional healthcare organizations state that quality care cannot be provided if patient preferences are not taken into consideration ( e.g., A merican Psy chiatric Association 20 06 ). A preference towards exposure based treatments is not uncommon; r esearch suggests that both parents of children and adolescents with anxiety disorders ( Brown et al. 2007 ; Lewin et al. 2014) and adult s with anxiety disorders ( Becker et al., 2007; Feeny et al. 2009; Patel & Simpson, 2010; Tarrier et al., 2006) prefer exposure based techniques over other psychotherapeutic or psychopharmacological treatments Failure to consider patient preferences

PAGE 42

42 commonly results in drop out from treatment and can hinder treatment outcome (Swift & Callahan, 2009; Swift, Callahan, Ivanovic, & Kominiak, 2013). Th e under utilization of TAIVE for pediatric anxiety observed in this study is not unexpected but especially alarming when vi ewed in the context of the d iffusion of innovation theory (Rodgers, 1962, 1983, 1995, 2003) This theory states that rapid adoption occurs in a social system once 10 25% of the members of the system adopt an innovation ( Rodgers 1995). Based on the percent ( 16.2% 29.1%; see Figure 1), it could be argued that we are in the midst of the tipping point in the fight to disseminate exposure based techniques into the community This implies that the re is immense potential for rapid integration of TAIVE into community practice and underscores the importance of further identification of barriers to adoption that, if addressed, will likely expedite the dissemination of exposure based techniques (Rodgers, 1983). T he diffusion of innovation principle also provides a theoretical explanation for why negative attitudes and beliefs about exposure based techniques appear to be the strong est pred ictor of TAIVE use As can be observed in Figure 1, the majority of the commu nity T he rate of adoption by those in the early majority and subsequent groups is largely influenced by their perception of mass op inion about an innovation (Freedman, 2002; Rodgers 1995, 2003). These perceptions are largely shaped by social forces such as word of mouth from opinion leaders in their social system ( Freedman, 2002; Rodgers 1995, 2003). In other words r esearch to pract ice gaps develop as improving empirical support of a treatment is not paralleled by an improving social perception of that treatment ( Tornatzky & Klein, 1982; Rodgers, 2003). Indeed, negative attitudes and beliefs about exposure based

PAGE 43

43 techniques abound in community providers ( Addis & Krasnow, 2000; Deacon, & Abramowitz, 2009; Deacon & Farrell, 2013; Deacon et al., 2013; Farrell et al. 2013; Feeny, Hembree, & Zoellner, 2004; Harned et al., 2013; Olatunji et al., 2007 ). Fortunately, n egative attitudes and b eliefs about exposure are m odifiable (Deacon et al., 2013; Harned et al., 2014) especially more so than some of the other predictors of dissemination that were not supported in this study (e.g., gender, temperament). A media campaign targeting community p roviders, such as through national email databases, could potentially be used to provide wide spread education on why exposure based techniques is effective tolerable and ethical In lieu of large scale media campaigns various types of training in exposure based techniques at the graduate and professional level ha ve been associated with improved negative attitudes and beliefs about exposures (Deacon et al., 2013; Harned et al., 2014; Reid et al., under review) and implementation of exposure based te chniques (Becker et al., 2004; Deacon et al., 2013; Gunter & Whittal, 2010; Harned et al., 2014 ; Howard, 1999; Sholomskas et al., 2005 ). Future research should use new analytical techniques (i.e., social network analyses) that can identify those who are op inion leaders for community practitioners (e.g., leaders of large private practices in a community ; television personalities, authors in commonly read journals such as American Psychologist ) and then study how to best improve the negative attitudes and bel iefs these leaders may have about exposure based techniques It likely will be important for these training programs to include in vivo exposure to exposure based techniques (Schare & Wyatt, 2013) as well as presentation of evidence that directly disprove s widely held negative attitudes and beliefs ( e.g., exposure based techniques do not cause higher drop out, Hembree et al., 2003; exposure based techniques do not worsen symptoms, Jayawickreme et al., 2014 ). Perhaps even

PAGE 44

44 policy level changes should be made such as testing knowledge of these techniques on licensure exams, which will serve as motivation to teach exposure based techniques in graduate school. In addition to negative attitudes and beliefs, other factors that may be associated with the adopti on of exposure based techniques need to be investigated. This study was the first to test multiple variables simultaneously in one model in order to identify the unique contribution of each variable. Using this approach, some findings were consistent with previous research (i.e., the importance of education in exposure based methods, self identification as a specialist, negative attitudes and beliefs about exposure) while other findings were inconsistent (e.g., the lack of importance of gender and temperame nt). When search ing for a practitioner to treat their child or adolescent with anxiety, parents may benefit from searching for practitioners who identify as specialists. Through the internet or discussions with the practitioner, parents may be able to asce rtain training history and negative attitudes and beliefs towards exposure based techniques and thus make a more informed decision about where to seek services This study is not without limitations. First, the sample collected was comprised largely of practitioners who reported working in some form of private practice. While this represents an important source of care being provided to the mentally ill in the community, the results of this study cannot be assumed to generalize to pr actitioners in community mental health systems. Unfortunately, the utilization of TAIVE and other empirically supported techniques is likely worse in community mental health systems than the poor utilization rates observed in private practice ( Ho gan 2003) A second limitation of this study was the use of a convenience sample rath er than a random sample However, our recruitment efforts successfully obtained a sample that was approximately proportionate to the geographic distribution of the United States

PAGE 45

45 po pulation and contained a diverse array of professionals who treat pediatric anxiety disorders. A third limitation is the potential that social desirability and recall bias are skewing the findings. While this study was not immune to these biases, efforts w ere taken to reduce their occurrence. Specifically, measures that were more specific to exposure based techniques were given later in the battery of measures. Furthermore, r esearch suggests online data collection may be more immune to this type of bias due to the privacy it provides (Palermo, Valenzuela, & Stork, 2004; Rhodes, Bowie, & Hergenrather, 2003; VanDenKerkhof, Goldstein, Blaine, & Rimmer, 2005). In order to reduce recall bias, participants were asked to provide data on treatments utilized within t he past 12 months. In conclusion, the dissemination of TAIVE (and other exposure based tech niques) is poor. T he results of this study suggest that the coming years are a critical period in the fi ght for improved dissemination and the key to success likel y revolves around improving the negative attitudes and beliefs about exposure based techniques held by community practitioners. If these negative attitudes and beliefs are not changed, the current research to practice gap will only grow. However, it is als o important to consider the global need for dissemination of evidenced based treatments such as CBT ET. Anxiety disorders commonly occur around the globe ( Kessler et al. 2009 ) and a large majority of these patients, especially those with Obsessive Compulsi ve Disorder, do not receive services (Kohn, Saxena, Levav, & Saraceno, 2004). This is concerning considering the empirically supported treatments that have been developed and the large global burden caused by anxiety disorders (Baxter, Vos, Scott, Ferrari, & Whiteford, 2014). It is safe to conclude that dissemination of evidenced based treatments such as TAIVE is a public health problem in the United States and even more so around the world That being said, positive strides

PAGE 46

46 have been made over the past dec ade (e.g., mand ates for evidenced based care) and, as stated earlier, the potential for rapid dissemination of TAIVE is high.

PAGE 47

47 Figure 4 1 TAIVE as a therapeutic tool for pediatric anxiety disorders, a frequency cut off was utilized based off treatment manuals for the various d isorders Specifically who endorsed using TAIVE at least 6 0% of the time to treat OCD (March & Mulle, 1998; Foa et al. 2012), 30% for PTSD ( Foa et al. 2008; TF CBT Web, 2005 ), 4 0% of the time to treat PD ( Angelosante et al., 2009 ; Pincus et al., 2010 ) and 60% of the time to treat SAD ( Kendall & Hedtke, 2006 ). Lower cut offs were made for PTSD and PD than OCD and SAD due to the equal importance of other exposure techniques such as trauma focused narrative for PTSD and interoceptive exposure for PD. PD (29.10%) OCD (25.40 %) SAD ( 20.7 0%) PTSD ( 16.20 %)

PAGE 48

48 REFERENCES Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive compulsive disorder: A meta analysis. Behavior T herapy 27 583 600. Abramowitz, J.S., Deacon, B. J., and Whiteside, S. P. (2010). Exposure therapy for anxiety: Principles and practice. New York: Guildford Press. Abramowitz, J. S., Franklin, M. E., & Foa, E. B. (2002). Empirical status of cognitive behavioral therapy for obsessive compulsive disorder: A meta analytic review. Romanian Journal of Cognitive and Behavioral Psychotherapies 2, 89 104. Addis, M. E., and Krasnow, A. D. (2000). A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals. Journal of Consulting and Cl inical Psychology 68 331. Allen, B., & Johnson, J. C. (2011). Utilization and Implementation of Trauma Focused Cognitive Behavioral Therapy for the Treatment of Maltreated Children. Child M altreatment 17 1 6. American Psychiatric Association (2006) Am erican Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorder Compendium A merican Psychiatric Association: Arlington, VA American Psychiatric Association. (2011). American Psychiatric Association Practice Guidelines Retrie ved from http://www.psychiatryonline.com/pracGuide/pracGuideHome.aspx Anderson, N. B. (2006). Evidenced based practice in psychology. American Psychologist 61 271 285. Angelosante, A. G., Pincus, D. B., Whitton, S. W., Cheron, D., & Pian, J. (2009). Implementation of an intensive treatment protocol for adolescents with panic disorder and agoraphobia. Cognitive and Behavioral Practice 16 345 357. Armfield, J. M. (2008). An experimental study of the role of vulnerability relat ed perceptions in spider fear: Comparing an imaginal and in vivo encounter. Journal of Anxiety D isorders 22 222 232. Bandelow, B., Seidler Brandler, U., Becker, A., Wedekind, D., & Rthe r, E. (2007). Meta analysis of randomized controlled comparisons of psychopharmacological an d psychological treatments for anxiety disorders. World Journal of Biological Psychiatry 8 175 187. Baxter, A. J., Scott, K. M., Ferrari, A. J., Norman, R. E., Vos, T., & Whiteford, H. A. (2014). rders: trends in the global prevalence of anxiety and depression between 1990 and 2010. Depression and A nxiety 31 506 516.

PAGE 49

49 Becker, C. B., Darius, E., & Schaumberg, K. (2007). An analog study of patient preferences for exposure versus alternative treatmen ts for posttraumatic stress disorder. Behaviour Research and Therapy 45 2861 2873. Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psycho and utilization of exposure therapy for PTSD. Behaviour Research and Therapy 42 277 292. distributions. Biometrika 41 302 316. Bhm, K., & Klz, A. (2008). Versorgungsrealitt der zwangsstrungen: we rden expositionsverfahren eingesetzt?. Verhaltenstherapie 18 18 24. Bouton, M. E. (2002). Context, ambiguity, and unlearning: sources of relaps e after behavioral extinction. Biological P sychiatry 52 976 986. Brown, A. M., Deacon, B. J., Abramowitz, J. S., Dammann, J., & Whitesi de, S. P. (2007). behavioral treatments for childhood anxiety disorders. Behaviour Research and T herapy 45 819 828. Connolly, S. D., & Bernstein, G. A. (2007). Practice parameter for the assessment an d treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry 46 267 283. Cook, J. M., Biyanova, T., Elhai, J., Schnurr, P. P., & Coyne, J. C. (2 010). What do psychotherapists really do in practice? An Internet study of over 2,000 practitioners. Psychotherapy: Theory, Research, Practice, Training 47 260. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chow dhury, N., & Baker, A. (2008). Optimizing inhibitory learning durin g exposure therapy. Behaviour Research and T herapy 46 5 27. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social P sychology 44 113. Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In Storch E. & McKay D. (Eds.), Handbook of treating variants and complications in anxiety disorders (pp 363 373). Springer: New York. Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J., Sy, J. T., Zhang, A. R., & McGrath, P. B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale. Journal of Anxiety D isorders 27 772 780. Deacon, B. J., Lickel, J. J., Fa rrell, N. R., Kemp, J. J., & Hipol, L. J. (20 13). Therapist perceptions and delivery of interoceptive exposure for panic disorder. Journal of Anxiety D isorders 27 259 264.

PAGE 50

50 Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction of behavioral avoidance in contamination fear. Behaviour Research and T herapy 45 2110 2120. Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma focused cognitive behavioral therapy for children: impact o f the trauma narrative and treatment length. Depression and Anxiety, 28 67 75. Farrell, N. R., Deacon, B. J., Kemp, J. J., Dixon, L. J., & Sy, J. T. (2013). Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investig ation. Journal of Anxiety D isorders 27 763 771. Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2004). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice 10 85 90. Feeny, N. C., Zoellner, L. A., Mavissakalian, M. R., & Roy By rne, P. P. (2009). What would you choose? Sertraline or prolonged exposure in community and PTSD treatment seeking women. Depression and A nxiety 26 724 731. Foa, E. B., Chrestman, K. R., & Gilboa Schechtman, E. (2008). Prolonged exposure therapy for adolescents with PTSD emotional processing of traumatic experiences, therapist guide (programs that work) New York: Oxford University Press Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: expos ure to corrective information. Psychologi ca l B ulletin 99 20 35. Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive Compulsive Disorder: Therapist Guide New York: Oxford University Press. Freeman, C. (2002). Continental, national and sub nation al innovation systems complementarity and economic growth. Research P olicy 31 191 211. Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive behavioral therapy for anxiety: Is dissemination working?. The Behavior Therapist 27 25 32. Greenber g, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R. Davidson, J. R., ... & Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry 60 427 435. Gunter, R. W., & Whittal, M. L. (2010) Dissemination of cognitive behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clinical Psychology R eview 30 194 202. Guzick, A.G ., Reid, A.M., Fernandez, A.G., Balkhi, A.M., Wippold, G.M., McNamara, J.P.H, Deacon, B.J., & Geffken, G.R. (2015, April). Preliminary Psychometrics of the Exposure Training Assessment. Poster to be presented at the 2015 University of Florida Public Health and Health Pr ofessions Research Day, Gainesville, FL.

PAGE 51

51 Haidt, J., McCauley, C., & Rozin, P. (1994). Individual differences in sensitivity to disgust: A scale sampling seven domains of disgust elicitors. Personality and Individual differences, 16 701 713. Harned, M. S., Dimeff, L. A., Woodcock, E. A., & Contreras, I. (2013). Predicting adoption of exposure therapy in a randomized controlled dissemination trial. Journal of Anxiety D isorders 27 754 762. Harned, M. S., Dimeff, L. A., Woodcock, E. A., Kelly, T., Zavertnik, J., Contreras, I., & Danner, S. M. (2014). Exposing clinicians to exposure: A randomized controlled d issemin ation trial of exposure therapy for anxiety d isorders. Behavior T herapy 45 731 744. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy 44 1 25. Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD?. Journal of Traumatic Stress 16 555 562. Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence based p rac tices for anxiety d isorders in wyoming: A survey of practicing p sychotherapists. Behavior M odification 37 170 188. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta analyses. Cognitive Therapy and R esearch 36 427 44 0. Hogan, M. F. (2003). New Freedom Commission report: the President's New Freedom Commission: recommendations to transform mental health care in America. Psychiatric Services 54 1467 1474. Howard, R. C. (1999). Treatment of anxiety diso rders: Does speci alty training help? Professional Psychology: Research and Practice 30 470. James, A. C., James, G., Cowdrey, F. A., Soler, A., & Choke, A. (2013). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Systemat ical Review 6. CD004690. Jayawickreme, N., Cahill, S. P., Riggs, D. S., Rauch, S. A., Resick, P. A., Rothbaum, B. O., & Foa, E. B. (2014). Primum non nocere (first do no harm): Symptom worsening and improvement in female assault victims after prolonged ex posure for PTSD. Depression and A nxiety 31 412 419. Jordan, C., Reid, A. M., Mariaskin, A., Augusto, B., & Sulkowski, M. L. (2 012). First Line Treatment for Pediatric Obsessive Compulsive Disorder. Journal of Contemporary Psychotherapy 42 243 248.

PAGE 52

52 Keller, M. B., Lavori, P. W., Wunder, J., Beardslee, W. R., Schwartz, C. E., & Roth, J. (1992). Chronic course of anxiety disorders in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 31 595 599. Kendall, P. C. Compton, S. N., Walkup, J. T., Birmaher, B., Albano, A. M., Sh errill, J., ... Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety D isorders 24 360 365. Kendall, P. C., & Hedtke, K. (2006a). Cognitive behavio ral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook. Kessler, R. C., Aguilar Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., ... & Wang, P. S. (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria S ociale 18 23 33. Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental health care. Bulletin of the World health Organization, 82 858 866. Lewin, A. B., McGui re, J. F., Murphy, T. K., & Storch, E. A. (2014). Editorial Perspective: The importance of considering parent's preferences when planning treatment for their children the case of childhood obsessive compulsive disorder. Journal of Child Psychology and Psychiatry 55 1314 1316. Lohr, J. M., Lilienfeld, S. O., & Rosen, G. M. (2012). Anxiety and its trea tment: Promoting science based practice. Journal of Anxiety D isorders 26 719 727. Mackun, P. & Wilson, S. (2011, March). Popu lation Distribution and Cha nge: 2000 to 2010. 2010 Census Briefs Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br 01.pdf March J, Mulle K. ( 1998 ) O CD in Children and Adolescents: A Cognitive Behavioral Treatment Manual. New York: Guilford Matchett, G., & Davey, G. C. (1991). A test of a disease avoidance model of animal phobias. Behaviour Research and T herapy 29 91 94. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., .. Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement (NCS A). Journal of the American Academy of Child and Adolescent Psychiatry 49 980 989. Meyer, J. M., Farrell, N. R., Kemp, J. J., Blakey, S. M., & Deacon, B. J. (2014). Why do clinicians exclude anxious clients from exposure therapy? Behaviour Research and T herapy 54 49 53. doi:10.1016/j.brat.2014.01.004 National In stitute for Clinical Excellence (2011). Clinical Guidelines Retrieved from http:/ /guidance.nice.org.uk/CG

PAGE 53

53 Oaten, M., Stevenson, R. J., & Case, T. I. (2009). Disgust as a disease avoidance mechanism. Psychological B ulletin 135 303. Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). The cruelest cure? Ethical issues in the imp lementation of exposure based treatments. Cognitive and Behavioral Practice 16 172 180. Olatunji, B. O., Williams, N. L., Tolin, D. F., Abramowitz, J. S., Sawchuk, C. N., Lohr, J. M., & Elwood, L. S. (2007). The Disgust Scale: item analysis, factor structure, and suggestions for refinement. Psychological A ssessment, 19 281. st, L.G., Ferebee, I., & Furmark, T. (1997). One session group therapy o f spider phobia: Direct versus indirect t reatments. Behaviour Research and Therapy, 35 721 732. Palermo, T. M., Valenzuela, D., & Stork, P. P. (2004). A randomized trial of electronic versus paper pain diaries in children: impact on compliance, accuracy, and acceptability. Pain 107 213 219. Pa rk, J. M., Small, B. J., Geller, D. A., Murphy, T. K., Lewin, A. B., & Storch, E. A. (2014). Does d Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive Compulsive Disorder? Journal of Child and Family S tudies 23 863 871. Patel, S. R., & Simpson, H. B. (2010). Patient Preferences for OCD treatment. The Journal of Clinical P sychiatry 71 1434. Perkonigg, A., Pfister, H., Stein, M. B., Hfler, M., Lieb, R., Maercker, A., & Wittchen, H. U. (2014). Longitudinal cour se of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. The American Journal of Psychiatry, 162 1320 1327. Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J. J., & McCraken, J. (2011). Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive compulsive disorder Journal of the American Academy of Child and Adolescent Psychiatry, 50, 1149 1161. Piacentini, J., Bergman, R. L., Keller, M., & McCracken, J. (2003). Functio nal impairment in children and adolescents with obsessive compulsive disorder. Journal of Child and Adolesce nt Psychopharmacology 13 61 69. Pincus, D. B., May, J. E., Whitton, S. W., Mattis, S. G., & Barlow, D. H. (2010). Cognitive behavioral treatment of panic disorder in adolescence. Journal of Clinical Child and Adolescent Psychology 39 638 649. Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk f or early adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General P sychiatry 55 56 64.

PAGE 54

54 Pediatric OCD Treatment Study Team. (2004) Cognitive behavior therapy, sertraline, and their combination for children and adolescents with obsessive compulsive disorder. Journal of the American Medical Association, 292 1969 1976. Rapee, R. M., Schniering, C. A., & Hudson, J. L. (2009). Anxiety d isorders during childhood and adolescence: Origins and treatment. Annual Review of Clinical P sychology 5 311 341. Rhodes, S. D., Bowie, D. A., & Hergenrather, K. C. (2003). Collecting behavioural data using the world wide web: considerations for researchers. Journal of Epidemiology and Community Health 57 68 73. Rogers, E. M. (1962). Diffusion of innovation New York: Free Press. Rogers, E. M. (1983). Diffusion of innovations ( 3 rd ed. ) New York: Free Press. Rogers, E. M. (1995). Diffusion of innovations (4 th ed.) New York: Free Press. Rogers, E. M. ( 2003 ). Diffusion of innovations (5 th ed.) New York: Free Press. Rodebaugh, T. L., Holaway, R. M ., & Heimberg, R. G. (2004). The treatme nt of social anxiety disorder. Clinical Psychology Review 24 883 908. Schare, M. L., & Wyatt, K. P. (2013). On the evolving nature of exposure therapy. Behavior M odification 37 243 256. Sholomskas, D. E., Syracus e Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don't train in vain: a dissemination trial of three strategies of training clinicians in cognitive behavioral therapy. Journal of Consulting and Clinical P sychology 73 106. Siev, J., & Chambless, D. L. (2007). Specificity of treatment effects: cognit ive therapy and relaxation for generalized anxiety and panic disorders. Journal of Consulting and C linical psychology 75 513. Simpson, G. A., Cohen, R. A., Pastor, P. N ., & Rueben, M. A. (2008). Use of mental health services in the past 12 months by children aged 4 17 years: United States, 2005 2006. N ational Center for Health Statistics Brief Data Number 8 Hyattsville, MD: National Center for Health Statistics. Sprang, G., Craig, C., & Clark, J. (2008). Factors impacting trauma treatment practice patterns: The convergence/divergence of science and practice. Journal of Anxiety D isorders 22 162 174. Storch, E. A., Bussing, R., Small, B. J., Geffken, G. R., McNamara, J. P., Rahman, O., ... & Murphy, T. K. (2013). Randomized, placebo controlled trial of cognitive behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive compulsive disorder. Behaviour Research and Therapy 51 823 829.

PAGE 55

55 Swi ft, J. K., & Callahan, J. L. (2009). The impact of client treatment preferences on outcome: a meta analysis. Journal of Clinical Psychology 65 368 381. Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013). Further examination of the psychot herapy preference effect: A meta regression analysis. Journal of Psychotherapy Integration 23 134. Tarrier, N., Liversidge, T., & Gregg, L. (2006). The acceptability and preference for the psychological treatment of PTSD. Behaviour Research and Therapy, 44 1643 1656. Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., ... & Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index 3. Psychologic al A ssessment 19 176. TF CBT Web (2005) A Web based learning course for Trauma Focused Cognitive Behavioral Therapy. Retrieved from www.musc.edu/tfcbt Tornatzky, L. G., & Johnson, E. C. (1982). Research on implementation: Implications for evaluation practice and evaluation policy. Evaluation and Program P lanning 5 193 198. Ultee, C. A., Griffioen, D., & Schellekens, J. (1982). The reduction of anxiet y in children: A comp arison of Behaviour Research and Therapy 20 61 67. van Minnen, A., Hendriks, L., & Olff, M. (2010). When do trauma exper ts choose exposure therapy for PTSD pat ients? A controlled study of therapist and patient factors. Behaviour Research and T herapy 48 312 320. VanDenKerkhof, E. G., Goldstein, D. H., Blaine, W. C., & Rimmer, M. J. (2005). A comparison of paper with electronic patient completed questionnaires i n a preoperative clinic. Anesthesia and Analgesia 101 1075 1080. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., She Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journ al of Medicine, 359 2753 2766. Wheaton, M. G., Deacon, B. J., McGrath, P. B., Berman, N. C., & Abramowitz, J. S. (2012). Dimensions of anxiety sensitivity in the anxiety disorders: Evaluation of the ASI 3. Journ al of Anxiety D isorders 26 401 408. Woodward, L. J., & Fergusson, D. M. (2001). Life course outcome s of young people with anxiety disorders in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 40 1086 1093. Woody, J. D., Anderson, D. K., D'Souza, H. J., Baxter, B., & Schubauer, J. (2015). Dissemination of Trauma Focused Cognitive Behavioral Therapy: A Follow Up Study of Practitioners' Knowledge and Implementation. Journal of Evidence Informed Social W ork 12 289 301.

PAGE 56

56 Zoellner, L. A., Feeny, N. C., Bittinger, J. N., Bedard Gilligan, M. A., Slagle, D. M., Post, L. M., & Chen, J. A. (2011). Teaching trauma focused exposu re therapy for PTSD: Critical clinical lessons for novice exposure therapists. Psychological Trauma: Theory, Research, Practice, and Policy 3 300.

PAGE 57

57 BIOGRAPHICAL SKETCH Adam M. Reid is a doctoral candidate in the Department of Clinical and Health Psychology at the University of Florida (UF) where he is currently completing his training under the mentorship of Dr. Gary Geffken. He is a graduate of the Department of Epidemiology where he completed his training interests relate to improving treatment outcome f or pediatric Obsessive Compulsive Disorder (OCD), advancing dissemination of evidenced based treatments for pediatric anxiety disorders, and increasing access to care for the underserved. In service of these interests, Mr. Reid frequently utilizes advanced statistical modeling and novel longitudinal designs resulting in significant methodological advances in the field of OCD assessment and treatment. Clinically, Mr. Reid is a senior graduate student clinician at the UF OCD Clinic and enjoys implementing exp osure based treatment methods to treat pediatric and adult anxiety disorders. He has also served as the student clinic director for Free Therapy Night, a community based psychological clinic in Gainesville that provides free psychological care to the under served. He will be completing his doctoral training at McLean Hospital, a Harvard Medical School affiliate hospital in 2015 2016.