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ViewAttendees 5

Symposia

Child / Adolescent - Anxiety

The SMART Study: A Clinical Effectiveness Trial of Pediatric Anxiety Treatment in a Diverse and Clinically Complex Sample

4 - (SYM 5) Exploring Exposures: Provider Perspectives of CBT Delivery to Underserved, Diverse Youth

Saturday, November 22, 2025
4:26 PM - 4:43 PM CST
Location: Bolden 5, Level 2
Keywords: Child, Anxiety, Treatment
Recommended Readings: Peterson BS, West AE, Weisz JR, et al. A Sequential Multiple Assignment Randomized Trial (SMART)study of medication and CBT sequencing in the treatment of pediatric anxiety disorders. BMC Psychiatry. Jun 30 2021;21(1):323. doi:10.1186/s12888-021-03314-y,   Walkup JT, Albano AM, Piacentini J, et al. Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety. New England Journal of Medicine. Dec 25 2008;359(26):2753-2766. doi:Doi10.1056/Nejmoa0804633,   Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety. Journal of Clinical Child & Adolescent Psychology. 2016/03/03 2016;45(2):91-113. doi:10.1080/15374416.2015.1046177,   Wang Z, Whiteside S, Sim L, et al. Anxiety in Children. Comparative Effectiveness Review No. 192.(Prepared by the Mayo Clinic Evidence-based Practice Center under Contract No. 290-2015-00013-I .) AHRQ Publication No. 17-EHC023-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2017.,   Strawn JR, Geracioti L, Rajdev N, Clemenza K, Levine A. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy. 2018;19(10):1057-1070. doi:10.1080/14656566.2018.1491966
Abstract Body

Background: Exposures, a core behavioral strategy in CBT designed to decrease anxiety through
systematic confrontation of the feared stimuli, may be a critical element in optimizing CBT
effectiveness. However, exposures are underutilized by mental health clinicians, particularly
when working with underserved, diverse youth with anxiety disorders in real-world settings.
Thus, gaining insight into mental health clinicians’ experiences in delivering exposures as part of
CBT is critical for effective implementation.

Objectives: This study qualitatively examined providers’ experiences with and perceptions of
exposure delivery to underserved, diverse youth with anxiety disorders.

Methods: We conducted semi-structured interviews with 37 real-world mental health providers
participating in a large-scale Sequential Multiple Assignment Randomized Trial (SMART) of
CBT and fluoxetine to treat anxiety in a population of youth 8-17 in Los Angeles County.
Interviews explored clinicians’ perceived strengths, challenges, acceptability, feasibility, and
implementation experiences, including barriers and facilitators of exposure delivery. Interviews
were recorded, transcribed verbatim, and coded independently by three team members. Analysis
was guided by Clarke and Braun's (2006) six phases of thematic analysis.

Results: Thematic analysis revealed three themes: 1) Caregiver involvement in exposure
delivery, 2) Impact of clinician self-efficacy and anxiety on exposure delivery, and 3) enhancing
engagement and acceptability through client-centered exposure design. Overall, we found
clinicians faced challenges navigating the complexities of exposure delivery in real-world
settings. The analysis also revealed a range of engagement strategies and adaptations clinicians
utilized to address these challenges to improve exposure engagement and effectiveness.

Conclusions: Future research should identify specific, evidence-based strategies and adaptations
to exposures to facilitate and optimize their delivery in real-world settings.  Additionally,
opportunities exist for the development and dissemination of best practice guidelines.