Abstract
Purpose of Review
Exposure and Response Prevention (ERP), the gold standard psychosocial treatment for pediatric OCD, is severely underutilized in routine practice. The majority of youth in need do not receive ERP, with minoritized youth being even less likely to receive and benefit from ERP. Improving the equitable implementation of ERP is pivotal to improving outcomes for youth with OCD. This article examines determinants of equitable implementation and the efforts to date to improve ERP access and response across multiple levels of implementation context (e.g., clinician, innovation, societal).
Recent Findings
Determinants exist across contextual levels that inhibit or promote ERP access and response including lack of ERP cultural responsiveness, clinician training and attitudes, client stigma, therapeutic alliance, organizational supports, and workforce shortages. Most efforts have been focused on improving access through clinician training. Emerging work has also attempted to address both access and response through expanding the workforce capacity and improving the cultural responsiveness of ERP.
Summary
The review highlights the complex, multifactorial efforts required to achieve equitable access and treatment outcomes for youth with OCD. Our review suggests that there has been a disproportionate effort to date to improve ERP access and response by targeting clinicians directly; however, sustained change is unlikely unless policy and structural factors are addressed.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Pediatric obsessive–compulsive disorder (OCD) affects up to 4% of youth [1,2,3,4] and leads to significant impairment in academic, social, and family functioning [5]. OCD typically onsets in childhood or adolescence [6]. Without intervention, OCD persists, leading to impaired occupational attainment and poor life satisfaction [7,8,9,10]. Early treatment is key to healthy functioning [11, 12]. Fortunately, psychotherapy options that ameliorate symptoms and reduce impairment exist for youth as young as three [13]. Gold-standard psychotherapy for pediatric OCD is cognitive behavioral therapy (CBT) that emphasizes exposure and response prevention (ERP) [13]. ERP supports youth to gradually face their fears (exposure) and reduce use of avoidance or compulsive behaviors (response prevention) to help youth tolerate distress more effectively. Unfortunately, most youth in need do not receive ERP [14, 15]. ERP is underutilized in routine clinical settings [16] with perhaps the largest research to practice gap compared to other psychotherapies [17,18,19]. Youth from minoritized backgrounds (i.e., individuals holding social identities subjected to systemic oppression and marginalization) are especially at risk for not receiving ERP [20,21,22,23], indicating concerning health inequities. Minoritized youth also are underrepresented in OCD research, lending uncertainty to the generalizability of current protocols [13]. There is an urgent need to improve access to effective ERP for all youth with OCD, with special consideration for minoritized youth. This requires ensuring that ERP is accessible and, when accessed, is responsive to youths’ diverse needs.
Implementation science, or the systematic study of how to support the successful uptake and utilization of evidence-based practices (EBPs), offers tools to understand why inequities in care reception persist [24]. Implementation science highlights the importance of the intersecting ecological factors, or determinants, that influence care delivery [24, 25]. The Health Equity Implementation Framework (HEIF) is one prominent implementation determinant framework that integrates principles of health equity with those of implementation science to ensure that implementation processes work toward equitable treatment access and response [25]. The HEIF comprises the following seven domains posited to influence care: the societal context (broader sociocultural and systemic factors that impact all implementation domains), characteristics of the innovation (ERP), provider factors, client factors, aspects of the clinical encounter (the dynamic between clients and providers during healthcare appointments), inner context (the local implementation setting, such as the clinic context), and the outer context (the broader cultural and regulatory healthcare systems) [25].
We first present an overview of what is known about key determinants to successful implementation of culturally responsive ERP for pediatric OCD, guided by the HEIF, as it relates both to equity in ERP access and treatment response. Although various EBPs exist for OCD, we focus on ERP because it is the most widely supported psychotherapy for OCD, and it is comparably efficacious to leading medications (selective serotonin reuptake inhibitors; e.g., [26]). We discuss each HEIF domain independently, although we acknowledge that these domains are interrelated. We then review efforts conducted to date to improve equitable ERP implementation. Finally, we conclude by providing recommendations for future directions to optimize the equitable implementation of ERP.
Determinants of Equitable ERP Implementation
Societal Context
The societal context consists of institutionally or structurally driven factors external to the healthcare system that influence service delivery including economic factors (e.g., funding for mental health care, economic opportunity), physical structures (e.g., availability of public transportation, physical infrastructure), and sociopolitical forces (e.g., structural oppression, institutional discrimination; [25]). For example, institutional discrimination can result in differential access to resources (e.g., housing, labor, and credit markets, education, and healthcare systems; [27]) that reduce access to mental health treatment [28, 29]. Empirical data linking the societal context itself to equitable OCD treatment access and response are scarce; however, they have downstream effects on all other contextual levels [25, 30] and will be described in more detail within each level.
Characteristics of the Innovation
Innovation characteristics posited to influence equitable care delivery within the HEIF include usability, clarity, underlying knowledge sources, degree of fit with existing practices, and evidence for the innovation [25, 31].
How Innovation Characteristics Influence Equitable ERP Access
The usability of ERP has been linked to implementation [32]. Specifically, ERP is a complex psychosocial treatment that requires substantial resources (e.g., time, access to expert consultation) to train and sustain its use. The difficulty of learning and implementing ERP likely contributes to its underutilization in routine practice settings [33]. Indeed, therapists report ERP is difficult to utilize even after intensive training [32]. Furthermore, the clarity of ERP, or the specific tasks a therapist must execute to deliver ERP, were not well delineated until recently; this “black box” nature of which ERP components are most critical to deliver [34] has hindered implementation efforts.
How Innovation Characteristics Influence Equitable ERP Response
ERP was developed and tested primarily within middle to upper income White communities, raising concern about ERP’s knowledge source. Leading protocols rarely systematically consider the cultural and contextual factors known to influence experiences with mental health and services for minoritized youth such as discrimination and poverty related stressors [35,36,37]. This is in part due to factors within the societal context, including institutional discrimination, that lead to underrepresentation of minoritized youth in research. The broader literature suggests culturally responsive care that specifically addresses aspects of culture and context (e.g., racism experiences, acculturation, poverty related stressors) can improve engagement and clinical outcomes for minoritized individuals [38,39,40], but no specific data for pediatric OCD exist.
Provider Factors
Provider, or clinician, factors have been most widely studied. Common determinants highlighted in the HEIF include provider knowledge, attitudes, biases, and cultural factors [25].
How Provider Characteristics Influence Equitable ERP Access
Likely in part due to the complexity of ERP (as described above), many providers lack the specialty training and associated knowledge to competently deliver ERP (e.g., [41, 42]). There is extensive data documenting that clinicians less familiar with ERP express negative beliefs that ERP can be harmful, unethical, or traumatizing, as ERP involves intentionally inducing distress in clients to support their ability to manage anxious feelings [43,44,45]. These negative beliefs are associated with underuse of ERP [41, 46, 47]. There is also growing evidence that many clinicians experience their own anxiety about using ERP with their clients, which persists even after training in ERP and leads them to underuse it or avoid it [47,48,49,50,51].
Relatedly, clinicians may hold misperceptions of with whom it is and is not appropriate to utilize ERP. For example, clinicians report reduced likelihood of using ERP with clients who are under seven, exhibit lower treatment engagement, are perceived to have limited coping skills, or experience family distress [41, 52, 53] despite limited to no empirical evidence suggesting these are contraindications for ERP. In addition, clinicians may undertreat and underdiagnose OCD-related symptoms in youth exposed to potentially traumatic events [54]. Factors within the societal context (e.g., identity-based discrimination) can lead to provider racial biases which may contribute to misdiagnosis of minoritized youth (e.g., [55]) and lack of proper treatment referral; research with adults demonstrates that minoritized adults are less likely to receive ERP for OCD-related symptoms than non-minoritized adults [56].
How Provider Characteristics Influence Equitable ERP Response
Little attention has been paid to how clinician factors inhibit or promote equity in treatment response in pediatric OCD treatment. A recent meta-analysis suggests that clinician level of therapy does not influence outcomes for youth with anxiety more generally [57]. While it has long been proposed that provider–client racial/ethnic match might impact treatment process and response (e.g., [58]), “data *demonstrating* benefits on engagement and *treatment outcomes” are inconclusive, and likely depend more on client preference and clinician’s cultural responsiveness [59,60,61]. However, this is understudied in pediatric OCD.
Client Factors
The HEIF highlights demographic variation (e.g., socioeconomic status, cultural factors), client beliefs and preferences, health literacy, and medical mistrust as key determinants to equitable implementation at the client level [25].
How Client Factors Influence Equitable ERP Access
Several client factors are known to impact ERP access [62, 63]. Importantly, many identified predictors of access stem from societal inequities and disproportionately present among youth of minoritized backgrounds. These inequities often create conditions in which minoritized communities are forced to prioritize basic needs over seeking mental health treatment [27]. For example, greater logistical barriers (e.g., scheduling and transportation problems, high costs associated with treatment) are associated with lower service use [64]. In addition, reduced mental health literacy in the form of low community awareness of how OCD manifests relative to mainstream perceptions of OCD as focused on cleanliness [65,66,67] and greater mistrust in services [64, 68] are known factors that can hinder ERP utilization (although data in youth specifically are more limited). Greater self-stigma is also hypothesized to impede service use as self-stigma related to disclosing obsessions is associated with internalized shame, leading individuals with OCD to conceal their symptoms; although formal data are lacking [69, 70].
How Client Factors Influence Equitable ERP Response
Research on client moderators of ERP outcomes has primarily focused on demographic variables and symptom severity, with inconsistent findings (see [71] for review). Cultural variation in symptom presentation (e.g., increased likelihood of contamination-related OCD symptoms in Black Americans due to fear of adhering to harmful stereotypes) and the extent to which they are recognized may influence the quality of care received, therefore impacting response [21, 64, 72]. In addition, emerging data in adults suggests that experiences of discrimination lead to OCD symptom exacerbation [21, 73]. Pinciotti and colleagues proposed that experiences of marginalization can influence OCD symptom presentation (e.g., individuals experiencing discrimination related to their queer identity may experience sexual orientation themes in obsessional content) that likely require adaptations to ERP to avoid unintentionally stigmatizing their minoritized identities, but data with youth is scant [73, 74].
Clinical Encounter
The clinical encounter refers to client-provider interactions; while not traditionally incorporated in implementation frameworks, this domain was incorporated into the HEIF given key factors within the clinical encounter (e.g., therapeutic alliance) are central to achieving equitable treatment response and access [25].
How the Clinical Encounter Influences Equitable ERP Access
In youth mental health services broadly, initial encounters with clinic staff have been found to influence access to and engagement with care. For example, when clinic staff assessed and proactively addressed potential barriers to treatment (e.g., telephone engagement interventions where clinic staff collaborated with clients to address potential barriers such as lack of transportation, time, and child care, and negative perceptions about services), families were more likely to initiate treatment [75]. Further, once engaged in care, integrating cultural assessments, such as the Cultural Formulation Interview, within an initial session can improve further engagement in care [40]. Less attention has been paid to the effects of factors within the clinical encounter on ERP access specifically.
How the Clinical Encounter Influences Equitable ERP Response
Clinical encounter influences are largely theoretical. Hypothesized determinants to successful treatment response include a strong therapeutic alliance, transparent communication, and shared decision making regarding client diagnoses and treatment [25, 76]. The therapeutic alliance is particularly central to successful OCD treatment due to ERP’s nature, which requires clients to engage in intentionally distressing scenarios. This requires significant trust in the provider [77]. In fact, longitudinal studies suggest that conducting ERP can strengthen the therapeutic alliance in treatment, perhaps because youth experience the potential utility of ERP firsthand and begin to place more trust in the provider’s ability to help them [32, 78, 79]; this can improve treatment response [80, 81].
Extra attention to the alliance and awareness of how to repair alliance ruptures when they occur may be required when considering equitable ERP implementation. Due to societal factors such as structural racism, youth from minoritized backgrounds are more likely to have experienced discrimination by healthcare providers and are at risk for initial mistrust [82, 83]. Clinicians may unintentionally engage in microaggressions (e.g., making assumptions based on cultural identity), which may further impair therapeutic alliance development [82] and worsen treatment outcomes when repairs are not made [84]. One strategy hypothesized to facilitate alliance building is shared decision making, which refers to collaboration between the provider, client, and family to identify target problems and select treatment techniques [85]. Shared decision making can facilitate incorporation of the client and families’ cultural beliefs, preferences, and values into ERP to enhance alliance and improve outcomes [76, 86].
Inner Context
The inner context refers to local and organizational settings in which ERP is implemented. Common determinants include formal and informal leadership support, organizational culture and climate, policies and procedures, and organizational priorities [25].
How the Inner Context Influences Equitable ERP Access
Key inner context determinants examined for ERP delivery include organizational climate and policies and procedures to support implementation. A commonly studied aspect of organizational climate is implementation climate, or the extent to which the organization supports and rewards the implementation and adoption of the intervention (in this case, ERP) for its clinicians [87, 88]. More positive implementation climate in community mental health is associated with more ERP delivery [16]. ERP is also hypothesized to require specific organizational policies, procedures, and cultural aspects in place to facilitate delivery, such as allowing clinicians to go off-site for ERP practices, having time to prepare for ERP sessions, a culture of collaboration with others in the organization, and resources to support ERP [89]. The extent to which clinics have the ability to mitigate effects of societal level barriers (e.g., transportation passes, flexible schedules, culturally diverse representation of clients and staff, gender affirming practices) can also impact client access to care [90], although this is understudied for pediatric OCD. Overall, these and other inner context determinants important for increasing EBP use (e.g., transformational leadership; Aarons et al. [91]) are understudied for ERP.
How the Inner Context Influences Equitable ERP Response
One potential determinant to equitable ERP response is clinical support; strategic supervision practices (e.g., clinician role plays a potential exposure practice with the supervisor and receives feedback) and other implementation supports (e.g., clinical guides for conducting exposures) may lead to higher quality ERP delivery, thus improving equitable response rates [33, 92, 93]. However, research on organizational strategies for improving equitable ERP response remains limited.
Outer Context
The outer context typically refers to the broader systems factors (e.g., structure of the healthcare system, funding policies, regulatory statutes) that influence implementation of EBPs [25].
How the Outer Context Influences Equitable Treatment Access
In the United States, specialty OCD care is concentrated in clinics that largely provide services to those clients who can afford to pay for out-of-pocket treatment [89], likely due in part to societal challenges related to insurance reimbursement and regulations. In contrast, clinicians working in the public system are more likely to work with minoritized youth and are often working in financially stressed settings with poor reimbursement rates that result in high productivity requirements and caseloads [94]. While formal costing of the training and consultation required to gain ERP competency has not yet been done (and remains an important area for future study), training in EBPs is costly [95] and cost-prohibitive to under resourced public mental health settings. Broader workforce issues also likely contribute to inequitable ERP access. Most mental health clinicians hold a master’s degree [96] and are unlikely to receive graduate training in specific EBPs like ERP [97]. Importantly, the mental health workforce is estimated to be over 70% White [98], indicating underrepresentation of those from minoritized backgrounds, an important consideration for ensuring that clients feel represented [99, 100]. Overall, a dearth of trained ERP providers, especially those that accept insurance, creates burden and stress on caregivers of youth with OCD to successfully engage with care; barriers are amplified for families also facing adverse social determinants of health [101].
How the Outer Context Influences Equitable Treatment Response
Systemic barriers and financial pressure contribute to elevated caseloads and high burnout among clinicians in the public sector [102]. High caseloads and billing expectations that result from outer context pressures leave limited time for the session planning [103], that is thought to be required to effectively deliver ERP [16]. While not yet examined for ERP directly, higher clinician burnout is associated with lower use of evidence-based interventions broadly [104]. Thus, we might expect that quality of ERP is at risk of being negatively impacted when delivered in a financially stressed, under-resourced setting relative to a traditional specialty clinic setting.
Efforts to Improve Equitable ERP Implementation
Enhancing Equity in ERP Access
To date, most resources have been directed toward addressing clinician barriers (e.g., anxiety and negative beliefs surrounding exposure) by training clinicians to increase ERP access, with mixed success. While traditional training efforts have reduced negative beliefs about exposure, they have had minimal impact on increasing clinician confidence or intention to use ERP [47, 105, 106]. Enhancing training with more experiential strategies (e.g., encouraging clinicians to do their own exposures to experience the benefit firsthand), client testimonials, directly addressing common misperceptions of exposure, ongoing consultation, and providing clear clinical implementation supports has led to increases in clinician ERP use compared to traditional training [33, 44, 107], although sustainment remains a concern [106]. Using an ERP model in training to support clinicians to overcome their own anxiety about ERP delivery (i.e., recognizing how clinician’s own negative beliefs can trigger avoidance of utilizing exposure practice with their client and then intentionally engaging in the practice exposure during training until they can tolerate the exposure) has also shown promise in early trials [108]. Limitations of training efforts to date include the relatively small number of clinicians targeted, minimal focus on pre-service training, and the lack of attention to organizational factors (e.g., supervision in exposure, clinician caseload capacity; [97, 109].
Beyond training, other emerging efforts to increase ERP access have included team-based (or “task-sharing”) models that train non-licensed providers to implement interventions in the context of pediatric OCD and anxiety to expand workforce capacity [110], co-location of ERP services in non-traditional mental health settings (e.g., schools, primary care) to increase reach to youth who may not attend traditional outpatient services [111, 112], and delivery of ERP via telehealth to improve access for clients who may face logistical barriers to traveling to on-site services or live in an area with few ERP providers [113,114,115,116]. Other efforts aim to circumvent workforce issues by delivering ERP via app-based tools [117]. Overall, there is emerging evidence for these efforts, with the most evidence to date for telehealth services. Limited work focuses specifically on pediatric OCD, and much is still uncertain about how to optimize their effectiveness.
There is a lack of state- and city-supported efforts to improve ERP access at the larger outer context and societal levels. A notable exception is New York, which is engaging in one of the only state-wide, systematic efforts to improve access to ERP [118]. We also are aware of one community-based clinic in Philadelphia that receives an enhanced billing rate for ERP to incentive its use. However, relative to other system-supported EBP implementation efforts, ERP lags behind (e.g., [119,120,121,122]).
Efforts to Enhance Equity in ERP Response
Recent work has aimed to improve ERP quality through provision of structured support tools to guide clinicians to meet benchmarks of ERP delivery with some success [33], but the impact of this on improving equity in treatment response is not yet known. The literature more broadly points to the importance of improving cultural responsiveness of care to improve outcomes. For example, careful attention to culturally normative behavior in diagnostic assessment and incorporating culturally and racially attuned strategies into ERP (e.g., psychoeducation about the impact of racism on symptomatology, extra sessions to build rapport) has been recommended to improve treatment response for minoritized individuals [123, 124]. Critically, while such guidelines exist and are derived from evidence, most have yet to be formally evaluated.
Critical Next Steps for Centering Equity in the Implementation of Pediatric OCD Treatment
Historically, equity has not been centered in pediatric OCD treatment research. There is much work to be done to improve equitable reach of ERP for youth suffering with OCD. The HEIF clearly highlights the complex, multifactorial efforts required to achieve equitable access and treatment outcomes for youth with OCD. Our review suggests that there has been a disproportionate effort to date to improve ERP access by targeting clinicians directly; however, sustained change is unlikely unless policy and structural factors are addressed.
Furthermore, there are clear gaps in the treatment literature as to how to optimize ERP to address unique needs of minoritized youth with OCD. A major tension in the field exists between what treatment practices are empirically tested and those that are theoretically derived but lack formal data to support them. In the absence of empirical data, relying on practice-based evidence will be essential for improving equitable ERP implementation. Such evidence must go beyond simple clinical reasoning and requires systematic assembly of existing data alongside clinical perspectives and the perspectives of those with lived experience to inform clinical recommendations. For example, emerging work by Sanchez and colleagues [125] developed the RESPECT (Revamping Evidence based Supports to Promote Effective Culturally responsive Treatment) Toolkit for Anxiety and OCD by combining insights from a rigorous review of previous treatment research, years of clinical experience working with and training clinicians to work with diverse populations, interviews with clinicians delivering services within specialty and community-based settings, and interviews with diverse clients and caregivers who received ERP in a community setting. Derived from data synthesis, the RESPECT Toolkit makes clinical recommendations for ensuring ERP delivery addresses key interrelated cultural (e.g., beliefs, values, and family norms related to identity) and contextual factors (e.g., the environment, systems, and structures in which youth live) that influence treatment [125].
We make the following recommendations for future research and practice aimed at advancing equitable implementation of ERP for pediatric OCD:
-
1.
Move beyond training individual clinicians in ERP to foster sustainable, organizational support for ERP in the settings where minoritized youth are likely to receive care. One viable, but understudied model is to test the creation of dedicated service lines for OCD treatment within community mental health centers (supported by organizational leaders) that approximate the structure of traditional specialty treatment clinics.
-
2.
Bolster the master’s level mental health workforce’s ability to deliver high-quality ERP. Clinicians early in their training and even undergraduate students can be trained to conduct exposure (e.g., [126, 127]). However, ERP is largely absent in master’s degree curricula. Improving pre-service training of clinicians in ERP holds high potential to impact current ERP underutilization. This could be done through specialized certificate programs adjunctive to traditional master’s degrees, perhaps created in partnership with specialty ERP treatment centers that can host trainees for fieldwork placements. Given workforce inequities, and common discrimination experienced by clinicians of color in their training, intentional efforts are needed to support clinicians from minoritized backgrounds within training programs (e.g., fellowships, culturally responsive environment, mentorship; [100, 128].
-
3.
Advance research on how to optimize task-shifting to increase workforce capacity to deliver ERP. The professional mental health workforce cannot fully meet demand for services. Community health workers can not only increase access to care in low-resourced community settings, but also increase cultural appropriateness of interventions because they are often from and work within the communities they serve [129]. Future research can build on emerging work on task-shifting in pediatric OCD and anxiety [110] by applying similar models of care to community settings serving youth with OCD.
-
4.
Leverage state and federal funds to effectively scale services across the public system. Larger-scale implementation efforts aimed at targeting clinician factors for ERP lag behind those of other leading youth EBPs that have received state and federal funds to support large-scale rollouts across the public health system (e.g., [130, 131]).
-
5.
Systems-level advocacy must work to change the current financial structures for ERP delivery that drive inequities. As long as insurance companies offer uncompetitive reimbursement rates and remain difficult to navigate when processing claims, ERP providers will continue to be driven out of the insurance market to private practice. This exacerbates inequities by making ERP accessible only to those who can afford to pay costly private practitioner rates.
-
6.
Continue research into how to optimize telehealth practices and technology-based treatments to improve reach of ERP to clients impacted by structural and logistic barriers to traditional session attendance. From an equity lens, careful consideration must be paid to costs associated with developed technology to ensure products do not further exacerbate disparities.
-
7.
Efforts to improve access to ERP must be conducted in conjunction with research aimed at improving responsiveness of ERP to youth of minoritized backgrounds. This includes training clinicians to understand how to address and discuss identity-based bias, in addition to their clients’ cultural and contextual factors relevant to care [38, 124]. Particularly for minoritized youth impacted by racism, the potential benefit of integrating manualized interventions for racial socialization [132] into ERP is an important area for future study. More funding and mechanistic work is needed to test clinical recommendations derived from practice-based evidence.
-
8.
Ensure representation of diverse individuals with lived experience of OCD in all aspects of future clinical research, from treatment development to implementation efforts.
Conclusion
All youth who are suffering from OCD should have the ability to access and receive effective ERP, regardless of their sociodemographic background. We are, unfortunately, far from achieving that goal. We argue that addressing systemic drivers of inequity and an intentional and explicit focus on how ERP requires adaptation to address the needs of minoritized youth is essential to overcoming the many barriers that youth with OCD currently face in receiving effective treatment.
Data Availability
No datasets were generated or analysed during the current study.
References
Canals J, Hernández-Martínez C, Cosi S, Voltas N. The epidemiology of obsessive–compulsive disorder in Spanish school children. J Anxiety Disord. 2012;26(7):746–52.
Fontenelle LF, Mendlowicz MV, Versiani M. The descriptive epidemiology of obsessive–compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30(3):327–37.
Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H, Goodman R. Prevalence of obsessive–compulsive disorder in the British nationwide survey of child mental health. Br J Psychiatry. 2001;179(4):324–9.
Osland S, Arnold PD, Pringsheim T. The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: a population-based Canadian study. Psychiatry Res. 2018;268:137–42.
Piacentini J, Bergman RL, Keller M, McCracken J. Functional impairment in children and adolescents with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol. 2003;13(supplement 1):61–9.
Dell’Osso B, Benatti B, Hollander E, Fineberg N, Stein DJ, Lochner C, et al. Childhood, adolescent and adult age at onset and related clinical correlates in obsessive–compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS). Int J Psychiatry Clin Pract. 2016;20(4):210–7.
Ezpeleta L, Keeler G, Erkanli A, Costello EJ, Angold A. Epidemiology of psychiatric disability in childhood and adolescence. J Child Psychol Psychiatry. 2001;42(7):901–14.
Mancebo MC, Boisseau CL, Garnaat SL, Eisen JL, Greenberg BD, Sibrava NJ, et al. Long-term course of pediatric obsessive-compulsive disorder: 3 years of prospective follow-up. Compr Psychiatry. 2014;55(7):1498–504 (2014/04/24 ed).
Micali N, Heyman I, Perez M, Hilton K, Nakatani E, Turner C, et al. Long-term outcomes of obsessive–compulsive disorder: follow-up of 142 children and adolescents. Br J Psychiatry. 2010;197(2):128–34.
Stewart SE, Geller DA, Jenike M, Pauls D, Shaw D, Mullin B, et al. Long-term outcome of pediatric obsessive–compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand. 2004;110(1):4–13.
Brakoulias V, Perkes IE, Tsalamanios E. A call for prevention and early intervention in obsessive-compulsive disorder. Early Interv Psychiatry. 2017;12(4):572–7.
Liu X, Fan Q. Early identification and intervention in pediatric obsessive-compulsive disorder. Brain Sci. 2023;13(3):399.
Freeman J, Benito K, Herren J, Kemp J, Sung J, Georgiadis C, et al. Evidence base update of psychosocial treatments for pediatric obsessive-compulsive disorder: evaluating, improving, and transporting what works. J Clin Child Adolesc Psychol. 2018;47(5):669–98.
Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev. 2006;26(7):817–33.
Schwartz C, Schlegl S, Kuelz AK, Voderholzer U. Treatment-seeking in OCD community cases and psychological treatment actually provided to treatment-seeking patients: a systematic review. J Obsessive-Compuls Relat Disord. 2013;2(4):448–56.
Becker-Haimes EM, Okamura KH, Wolk CB, Rubin R, Evans AC, Beidas RS. Predictors of clinician use of exposure therapy in community mental health settings. J Anxiety Disord. 2017;49:88–94 (2017/04/27 ed).
Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence base update: 50 years of research on treatment for child and adolescent anxiety. J Clin Child Adolesc Psychol. 2015;45(2):91–113.
McLeod BD, Southam-Gerow MA, Jensen-Doss A, Hogue A, Kendall PC, Weisz JR. Benchmarking treatment adherence and therapist competence in individual cognitive-behavioral treatment for youth anxiety disorders. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53. 2019;48(sup1):S234-46 (2017/10/20 ed).
Smith MM, McLeod BD, Southam-Gerow MA, Jensen-Doss A, Kendall PC, Weisz JR. Does the delivery of CBT for youth anxiety differ across research and practice settings? Behav Ther. 2017;48(4):501–16 (2016/08/06 ed).
de la Cruz LF, Llorens M, Jassi A, Krebs G, Vidal-Ribas P, Radua J, et al. Ethnic inequalities in the use of secondary and tertiary mental health services among patients with obsessive–compulsive disorder. Br J Psychiatry. 2015;207(6):530–5.
Williams MT, Jahn ME. Obsessive–compulsive disorder in African American children and adolescents: risks, resiliency, and barriers to treatment. Am J Orthopsychiatry. 2017;87(3):291–303.
Williams M, Powers M, Yun YG, Foa E. Minority participation in randomized controlled trials for obsessive-compulsive disorder. J Anxiety Disord. 2010;24(2):171–7.
Wetterneck CT, Little TE, Rinehart KL, Cervantes ME, Hyde E, Williams M. Latinos with obsessive-compulsive disorder: mental healthcare utilization and inclusion in clinical trials. J Obsessive-Compuls Relat Disord. 2012;1(2):85–97 (2012/01/08 ed).
Bauer MS, Kirchner J. Implementation science: what is it and why should I care? Psychiatry Res. 2020;283:112376.
Woodward EN, Singh RS, Ndebele-Ngwenya P, Melgar Castillo A, Dickson KS, Kirchner JE. A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implement Sci Commun. 2021;2(1):61–61.
Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, et al. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA. 2011;306(11):1224–32.
Castro-Ramirez F, Al-Suwaidi M, Garcia P, Rankin O, Ricard JR, Nock MK. Racism and poverty are barriers to the treatment of youth mental health concerns. J Clin Child Adolesc Psychol. 2021;50(4):534–46.
Neblett EW. Racism and health: challenges and future directions in behavioral and psychological research. Cultur Divers Ethnic Minor Psychol. 2019;25(1):12–20.
Alvarez K, Cervantes PE, Nelson KL, Seag DEM, Horwitz SM, Hoagwood KE. Review: structural racism, children’s mental health service systems, and recommendations for policy and practice change. J Am Acad Child Adolesc Psychiatry. 2022;61(9):1087–105 (2021/12/28 ed).
Adsul P, Shelton RC, Oh A, Moise N, Iwelunmor J, Griffith DM. Challenges and opportunities for paving the road to global health equity through implementation science. Annu Rev Public Health [Internet]. 2024;45(1). https://doi.org/10.1146/annurev-publhealth-060922-034822.
Damschroder LJ, Reardon CM, Opra Widerquist MA, Lowery J. Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum. Implement Sci IS. 2022;17(1):7–7.
Chu BC, Colognori DB, Yang G, Xie M ge, Lindsey Bergman R, Piacentini J. Mediators of exposure therapy for youth obsessive-compulsive disorder: specificity and temporal sequence of client and treatment factors. Behav Ther. 2015;46(3):395–408.
Benito KG, Herren J, Freeman JB, Garcia AM, Block P, Cantor E, et al. Improving delivery behaviors during exposure for pediatric OCD: a multiple baseline training trial with community therapists. Behav Ther. 2021;52(4):806–20 (2020/10/24 ed).
Garcia AM. Exposure tasks in anxiety treatment: a black box that still needs unpacking. J Am Acad Child Adolesc Psychiatry. 2017;56(12):1010–1.
Benish SG, Quintana S, Wampold BE. Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta-analysis. J Couns Psychol. 2011;58(3):279–89.
Georgiadis C, Bose D, Wolenski R, Javadi N, Coxe S, Pettit JW, et al. How flexible are treatments for youth internalizing disorders? Examining modification guidelines included across supported treatments. J Clin Child Adolesc Psychol. 2022;51(5):593–609.
Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder AMB, Nadal KL, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271–86.
Huey SJ, Park AL, Galán CA, Wang CX. Culturally responsive cognitive behavioral therapy for ethnically diverse populations. Annu Rev Clin Psychol. 2023;19(1):51–78.
Hall GCN, Berkman ET, Zane NW, Leong FTL, Hwang WC, Nezu AM, et al. Reducing mental health disparities by increasing the personal relevance of interventions. Am Psychol. 2021;76(1):91–103.
Sanchez AL, Jent J, Aggarwal NK, Chavira D, Coxe S, Garcia D, et al. Person-centered cultural assessment can improve child mental health service engagement and outcomes. J Clin Child Adolesc Psychol. 2021;51(1):1–22.
Reid AM, Guzick AG, Fernandez AG, Deacon B, McNamara JPH, Geffken GR, et al. Exposure therapy for youth with anxiety: utilization rates and predictors of implementation in a sample of practicing clinicians from across the United States. J Anxiety Disord. 2018;58:8–17.
van Minnen A, Hendriks L, Olff M. When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behav Res Ther. 2010;48(4):312–20.
Deacon BJ, Farrell NR, Kemp JJ, Dixon LJ, Sy JT, Zhang AR, et al. Assessing therapist reservations about exposure therapy for anxiety disorders: the therapist beliefs about exposure scale. J Anxiety Disord. 2013;27(8):772–80.
Farrell NR, Kemp JJ, Blakey SM, Meyer JM, Deacon BJ. Targeting clinician concerns about exposure therapy: a pilot study comparing standard vs. enhanced training. Behav Res Ther. 2016;85:53–9.
Olatunji BO, Deacon BJ, Abramowitz JS. The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cogn Behav Pract. 2009;16(2):172–80.
de Jong R, Lommen MJJ, van Hout WJPJ, de Jong PJ, Nauta MH. Therapists’ characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth: a survey among Dutch-speaking mental health practitioners. J Anxiety Disord. 2020;73:102230.
Trivasse H, Webb TL, Waller G. A meta-analysis of the effects of training clinicians in exposure therapy on knowledge, attitudes, intentions, and behavior. Clin Psychol Rev. 2020;80:101887.
Becker-Haimes EM, Klein CC, Frank HE, Oquendo MA, Jager-Hyman S, Brown GK, et al. Clinician maladaptive anxious avoidance in the context of implementation of evidence-based interventions: a commentary. Front Health Serv. 2022;2:833214 (2022/06/09 ed).
Farrell NR, Deacon BJ, Kemp JJ, Dixon LJ, Sy JT. Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation. J Anxiety Disord. 2013;27(8):763–71.
Pittig A, Kotter R, Hoyer J. The struggle of behavioral therapists with exposure: self-reported practicability, negative beliefs, and therapist distress about exposure-based interventions. Behav Ther. 2019;50(2):353–66.
Scherr SR, Herbert JD, Forman EM. The role of therapist experiential avoidance in predicting therapist preference for exposure treatment for OCD. J Context Behav Sci. 2015;4(1):21–9.
Meyer JM, Farrell NR, Kemp JJ, Blakey SM, Deacon BJ. Why do clinicians exclude anxious clients from exposure therapy? Behav Res Ther. 2014;54:49–53.
Whiteside SPH, Deacon BJ, Benito K, Stewart E. Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. J Anxiety Disord. 2016;40:29–36 (2016/04/06 ed).
Becker-Haimes EM, Wislocki K, DiDonato S, Beidas RS, Jensen-Doss A. Youth trauma histories are associated with under-diagnosis and under-treatment of co-occurring youth psychiatric symptoms. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53. 2023;52(2):184–95 (2021/05/26 ed).
Fadus MC, Ginsburg KR, Sobowale K, Halliday-Boykins CA, Bryant BE, Gray KM, et al. Unconscious bias and the diagnosis of disruptive behavior disorders and ADHD in African American and Hispanic youth. Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2020;44(1):95–102 (2019/11/11 ed).
Katz JA, Rufino KA, Werner C, McIngvale E, Storch E. OCD in ethnic minorities. Clin Exp Psychol. 2020;6(1):1–6.
Walsh LM, Roddy MK, Scott K, Lewis CC, Jensen-Doss A. A meta-analysis of the effect of therapist experience on outcomes for clients with internalizing disorders. Psychother Res J Soc Psychother Res. 2019;29(7):846–59 (2018/05/03 ed).
Smith TB, Trimble JE. Matching clients with therapists on the basis of race or ethnicity: a meta-analysis of clients’ level of participation in treatment. Found Multicult Psychol Res Inf Eff Pract. 2016;115–28. https://doi.org/10.1037/14733-006.
Cabral RR, Smith TB. Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. J Couns Psychol. 2011;58(4):537–54.
Chu W, Chorpita BF, Becker KD. Race, racial matching, and cultural understanding as predictors of treatment engagement in youth mental health services. Psychother Res. 2022;33(5):669–82.
Owen J, Tao KW, Drinane JM, Hook J, Davis DE, Kune NF. Client perceptions of therapists’ multicultural orientation: cultural (missed) opportunities and cultural humility. Prof Psychol Res Pract. 2016;47(1):30–7.
Garcia AM, Sapyta JJ, Moore PS, Freeman JB, Franklin ME, March JS, et al. Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I). J Am Acad Child Adolesc Psychiatry. 2010;49(10):1024–86 (2010/09/06 ed).
Peris TS, Piacentini J. Optimizing treatment for complex cases of childhood obsessive compulsive disorder: a preliminary trial. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53. 2013;42(1):1–8 (2012/05/01 ed).
Williams MT, Domanico J, Marques L, Leblanc NJ, Turkheimer E. Barriers to treatment among African Americans with obsessive-compulsive disorder. J Anxiety Disord. 2012;26(4):555–63 (2012/02/10 ed).
García-Soriano G, Roncero M. What do Spanish adolescents think about obsessive-compulsive disorder? Mental health literacy and stigma associated with symmetry/order and aggression-related symptoms. Psychiatry Res. 2017;250:193–9.
Coles ME, Heimberg RG, Weiss BD. The public’s knowledge and beliefs about obsessive compulsive disorder. Depress Anxiety. 2013;30(8):778–85.
Hathorn SK, Lochner C, Stein DJ, Bantjes J. Help-Seeking intention in obsessive-compulsive disorder: predictors and barriers in South Africa. Front Psychiatry. 2021;24(12):733773–733773.
Kolvenbach S, Fernández de la Cruz L, Mataix-Cols D, Patel N, Jassi A. Perceived treatment barriers and experiences in the use of services for obsessive–compulsive disorder across different ethnic groups: a thematic analysis. Child Adolesc Ment Health. 2016;23(2):99–106.
Ponzini GT, Steinman SA. A systematic review of public stigma attributes and obsessive–compulsive disorder symptom subtypes. Stigma Health. 2022;7(1):14–26.
Stengler-Wenzke K, Trosbach J, Dietrich S, Angermeyer MC. Experience of stigmatization by relatives of patients with obsessive compulsive disorder. Arch Psychiatr Nurs. 2004;18(3):88–96.
Norris LA, Kendall PC. Moderators of outcome for youth anxiety treatments: current findings and future directions. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53. 2021;50(4):450–63 (53. 2020/11/03 ed).
Wilson A, Thayer K. Cross-cultural differences in the presentation and expression of OCD in Black individuals: a systematic review. J Obsessive-Compuls Relat Disord. 2020;27:100592.
Pinciotti CM, Nuñez M, Riemann BC, Bailey BE. Clinical presentation and treatment trajectory of gender minority patients with obsessive-compulsive disorder. J Cogn Psychother. 2022;36(1):42–59.
Pinciotti CM, Smith Z, Singh S, Wetterneck CT, Williams MT. Call to action: recommendations for justice-based treatment of obsessive-compulsive disorder with sexual orientation and gender themes. Behav Ther. 2022;53(2):153–69.
McKay MM, Hibbert R, Hoagwood K, Rodriguez J, Murray L, Legerski J, et al. Integrating evidence-based engagement interventions into “real world” child mental health settings. Brief Treat Crisis Interv. 2004;4(2):177–86.
Rodenburg-Vandenbussche S, Carlier I, van Vliet I, van Hemert A, Stiggelbout A, Zitman F. Patients’ and clinicians’ perspectives on shared decision-making regarding treatment decisions for depression, anxiety disorders, and obsessive-compulsive disorder in specialized psychiatric care. J Eval Clin Pract. 2019;26(2):645–58.
Buchholz JL, Abramowitz JS. The therapeutic alliance in exposure therapy for anxiety-related disorders: a critical review. J Anxiety Disord. 2020;70:102194.
Kendall PC, Comer JS, Marker CD, Creed TA, Puliafico AC, Hughes AA, et al. In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders. J Consult Clin Psychol. 2009;77(3):517–25.
Creed TA, Kendall PC. Therapist alliance-building behavior within a cognitive-behavioral treatment for anxiety in youth. J Consult Clin Psychol. 2005;73(3):498–505.
Wheaton MG, Mcingvale E, Van Meter AR, Björgvinsson T. Quality of the therapeutic working alliance as a factor in intensive residential treatment of obsessive-compulsive disorder. Psychother Res. 2022;33(4):442–54.
Wolf N, van Oppen P, Hoogendoorn AW, van Balkom AJLM, Visser HAD. Therapeutic alliance and treatment outcome in cognitive behavior therapy for obsessive-compulsive disorder. Front Psychiatry. 2022;24(13):658693–658693.
Owen J, Tao KW, Imel ZE, Wampold BE, Rodolfa E. Addressing racial and ethnic microaggressions in therapy. Prof Psychol Res Pract. 2014;45(4):283–90.
Williams MT, Taylor RJ, Mouzon DM, Oshin LA, Himle JA, Chatters LM. Discrimination and symptoms of obsessive-compulsive disorder among African Americans. Am J Orthopsychiatry. 2017;87(6):636–45 (2017/08/17 ed).
McLaughlin AA, Keller SM, Feeny NC, Youngstrom EA, Zoellner LA. Patterns of therapeutic alliance: rupture-repair episodes in prolonged exposure for posttraumatic stress disorder. J Consult Clin Psychol. 2014;82(1):112–21 (2013/11/04 ed).
Langer DA, Jensen-Doss A. Shared decision-making in youth mental health care: using the evidence to plan treatments collaboratively. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53. 2018;47(5):821–31 (53. 2016/12/02 ed).
Langer DA, Holly LE, Wills CE, Tompson MC, Chorpita BF. Shared decision-making for youth psychotherapy: a preliminary randomized clinical trial on facilitating personalized treatment. J Consult Clin Psychol. 2022;90(1):29–38 (2021/12/23 ed).
Klein KJ, Sorra JS. The challenge of innovation implementation. Acad Manage Rev. 1996;21(4):1055–80.
Jacobs SR, Weiner BJ, Reeve BB, Hofmann DA, Christian M. The missing link: a test of Klein and Sorra’s proposed relationship between implementation climate, innovation-values fit and implementation effectiveness. Implement Sci [Internet]. 2015;10(S1). https://doi.org/10.1186/1748-5908-10-s1-a18.
Becker-Haimes EM, Byeon YV, Frank HE, Williams NJ, Kratz HE, Beidas RS. Identifying the organizational innovation-specific capacity needed for exposure therapy. Depress Anxiety. 2020;37(10):1007–16.
Zerrate Parra MC, Ortin-Peralta A, Erban R, Reyes-Portillo J, Schonfeld Reichel E, Desai P, et al. Providing evidence-based and culturally competent care to racial/ethnic minority young adults with anxiety disorders: the experience of an urban medical center clinic. Evid-Based Pract Child Adolesc Ment Health. 2020;5(2):189–207.
Aarons GA. Transformational and transactional leadership: Association with attitudes toward evidence-based practice. Psychiatric services. 2006;57(8):1162–9.
Ringle VA, Read KL, Edmunds JM, Brodman DM, Kendall PC, Barg F, et al. Barriers to and facilitators in the implementation of cognitive-behavioral therapy for youth anxiety in the community. Psychiatr Serv Wash DC. 2015;66(9):938–45 (2015/05/15 ed).
Schriger SH, Boroshok AL, Khan AN, Wang L, Becker-Haimes EM. A case example of community-based supervision to overcome barriers and support the implementation of exposure therapy. Psychol Serv. 2023;20(2):343–52.
Stewart RE, Adams DR, Mandell DS, Hadley TR, Evans AC, Rubin R, et al. The perfect storm: collision of the business of mental health and the implementation of evidence-based practices. Psychiatr Serv Wash DC. 2016;67(2):159–61 (2015/11/02 ed).
Okamura KH, Benjamin Wolk CL, Kang-Yi CD, Stewart R, Rubin RM, Weaver S, et al. The price per prospective consumer of providing therapist training and consultation in seven evidence-based treatments within a large public behavioral health system: an example cost-analysis metric. Front Public Health. 2018;8(5):356–356.
Health Resources and Services Administration (HRSA) health workforce. Behavioral health workforce projection, 2017–2030. 2016.
Becker-Haimes EM, Okamura KH, Baldwin CD, Wahesh E, Schmidt C, Beidas RS. Understanding the landscape of behavioral health pre-service training to inform evidence-based intervention implementation. Psychiatr Serv. 2019;70(1):68–70.
Bureau of Labor Statistics. Current Population Survey. 2024.
Kyere E, Fukui S. Structural racism, workforce diversity, and mental health disparities: a critical review. J Racial Ethn Health Disparities. 2023;10(4):1985–96 (2022/08/05 ed).
Sanchez AL, Cliggitt LP, Dallard NL, Irby D, Harper M, Schaffer E, et al. Power redistribution and upending white supremacy in implementation research and practice in community mental health. Psychiatr Serv. 2023;74(9):987–90.
Frank HE, Cain G, Freeman J, Benito KG, O’Connor E, Kemp J, et al. Parent-identified barriers to accessing exposure therapy: a qualitative study using process mapping. Front Psychiatry. 2023;14:1068255.
Kim JJ, Brookman-Frazee L, Gellatly R, Stadnick N, Barnett ML, Lau AS. Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health. Prof Psychol Res Pract. 2018;49(2):131–42.
Last BS, Mirhashem R, Yang Y. From plan to practice: a qualitative study of public mental health therapists’ session-planning practices. Psychol Serv [Internet]. 2024. https://doi.org/10.1037/ser0000840.
Lau AS, Lind T, Crawley M, Rodriguez A, Smith A, Brookman-Frazee L. When do therapists stop using evidence-based practices? Findings from a mixed method study on system-driven implementation of multiple EBPs for children. Adm Policy Ment Health. 2020;47(2):323–37.
Frank HE, Becker-Haimes EM, Kendall PC. Therapist training in evidence-based interventions for mental health: a systematic review of training approaches and outcomes. Clin Psychol Publ Div Clin Psychol Am Psychol Assoc. 2020;27(3):e12330.
Chu BC, Talbott Crocco S, Arnold CC, Brown R, Southam-Gerow MA, Weisz JR. Sustained implementation of cognitive-behavioral therapy for youth anxiety and depression: long-term effects of structured training and consultation on therapist practice in the field. Prof Psychol Res Pract. 2015;46(1):70.
Frank HE, Becker-Haimes EM, Rifkin LS, Norris LA, Ollendick TH, Olino TM, et al. Training with tarantulas: a randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training. J Anxiety Disord. 2020;76:102308–102308 (2020/09/17 ed).
Kemp J, Benito K, Herren J, Brown Z, Frank HE, Freeman J. Exposure to exposure: a protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation. Front Psychiatry. 2023;15(14):1096259–1096259.
Beidas RS, Kendall PC. Training therapists in evidence-based practice: a critical review of studies from a systems-contextual perspective. Clin Psychol Publ Div Clin Psychol Am Psychol Assoc. 2010;17(1):1–30.
Jackson M, Kemp J, Freeman J. A team-based service model for increasing equitable access to care. Brown Univ Child Adolesc Behav Lett. 2023;39(10):1–4.
Masia Warner C, Colognori D, Brice C, Herzig K, Mufson L, Lynch C, et al. Can school counselors deliver cognitive-behavioral treatment for social anxiety effectively? A randomized controlled trial. J Child Psychol Psychiatry. 2016;57(11):1229–38.
Sloman GM, Gallant J, Storch EA. A school-based treatment model for pediatric obsessive-compulsive disorder. Child Psychiatry Hum Dev. 2007;38(4):303–19.
Comer JS, Furr JM, Kerns CE, Miguel E, Coxe S, Elkins RM, et al. Internet-delivered, family-based treatment for early-onset OCD: a pilot randomized trial. J Consult Clin Psychol. 2017;85(2):178–86 (2016/11/21 ed).
Aspvall K, Lenhard F, Melin K, Krebs G, Norlin L, Näsström K, et al. Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: lessons from clinics in Sweden, United Kingdom and Australia. Internet Interv. 2020;27(20):100308–100308.
Islam S, Sanchez AL, McDermott CL, Clapp D, Worley J, Becker-Haimes EM. To proceed via telehealth or not? Considerations for pediatric anxiety and related disorders beyond COVID-19. Cogn Behav Pract. 2023. https://doi.org/10.1016/j.cbpra.2023.01.004.
Frank AC, Li R, Peterson BS, Narayanan SS. Wearable and mobile technologies for the evaluation and treatment of obsessive-compulsive disorder: scoping review. JMIR Ment Health. 2023;18(10):e45572–e45572.
Wolters LH, Weidle B, Babiano-Espinosa L, Skokauskas N. Feasibility, acceptability, and effectiveness of Enhanced Cognitive Behavioral Therapy (eCBT) for children and adolescents with obsessive-compulsive disorder: protocol for an open trial and therapeutic intervention. JMIR Res Protoc. 2020;9(12):e24057–e24057.
Patel SR, Gershkovich M, Hinds M, Jankowski SE, Dixon LB, Myers RW, et al. Statewide workforce development program to improve care for individuals with obsessive-compulsive disorder. Psychiatr Serv. 2022;73(3):343–5.
Nakamura BJ, Chorpita BF, Hirsch M, Daleiden E, Slavin L, Amundson MJ, et al. Large-scale implementation of evidence-based treatments for children 10 years later: Hawaii’s evidence-based services initiative in children’s mental health. Clin Psychol Sci Pract. 2011;18(1):24–35.
Powell BJ, Beidas RS, Rubin RM, Stewart RE, Wolk CB, Matlin SL, et al. Applying the policy ecology framework to Philadelphia’s behavioral health transformation efforts. Adm Policy Ment Health. 2016;43(6):909–26.
Rivera Nales CJ, Triplett NS, Woodard GS, Meza R, Valdivieso A, Goel V, et al. CBT+ training initiative in Washington state community mental health: an evaluation of child clinical outcomes. Community Ment Health J. 2023;60(4):649–61.
Southam-Gerow MA, Daleiden EL, Chorpita BF, Bae C, Mitchell C, Faye M, et al. MAPping Los Angeles County: taking an evidence-informed model of mental health care to scale. J Clin Child Adolesc Psychol. 2013;43(2):190–200.
Graham-LoPresti JR, Gautier SW, Sorenson S, Hayes-Skelton SA. Culturally sensitive adaptations to evidence-based cognitive behavioral treatment for social anxiety disorder: a case paper. Cogn Behav Pract. 2017;24(4):459–71.
Williams MT, Rouleau TM, La Torre JT, Sharif N. Cultural competency in the treatment of obsessive-compulsive disorder: practitioner guidelines. Cogn Behav Ther [Internet]. 2020;13. https://doi.org/10.1017/s1754470x20000501.
Sanchez AL, Weiss M, Schacter T, Baumann A, Calloway A, Davis Goodwine DM, Mora Ringle V, Becker-Haimes EM. The development of a toolkit to improve the cultural responsiveness of treatment for marginalized youth with anxiety and OCD. Presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, New York, NY; 2022.
Cornacchio D, Furr JM, Sanchez AL, Hong N, Feinberg LK, Tenenbaum R, et al. Intensive group behavioral treatment (IGBT) for children with selective mutism: a preliminary randomized clinical trial. J Consult Clin Psychol. 2019;87(8):720–33.
McCarty RJ, Cooke DL, Lazaroe LM, Guzick AG, Guastello AD, Budd SM, et al. The effects of an exposure therapy training program for pre-professionals in an intensive exposure-based summer camp. Cogn Behav Ther [Internet]. 2022;15. https://doi.org/10.1017/s1754470x22000010.
Galán CA, Bowdring MA, Tung I, Sequeira SL, Call CC, Savell S, et al. Real change or performative anti-racism? Clinical psychology programs’ efforts to recruit and retain BIPOC scholars. J Clin Child Adolesc Psychol. 2023;52(3):411–26.
Barnett ML, Klein CC, Gonzalez JC, Sanchez BE, Rosas YG, Corcoran F. How do lay health worker engage caregivers? A qualitative study to enhance equity in evidence-based parenting programs. Evid-Based Pract Child Adolesc Ment Health. 2023;8(2):221–35 (2021/11/04 ed).
Amaya-Jackson L, Hagele D, Sideris J, Potter D, Briggs EC, Keen L, et al. Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth. BMC Health Serv Res. 2018;18(1):589–589.
Hanson CL, Crandall A, Barnes MD, Magnusson B, Novilla MLB, King J. Family-focused public health: supporting homes and families in policy and practice. Front Public Health. 2019;20(7):59–59.
Metzger IW, Anderson RE, Are F, Ritchwood T. Healing interpersonal and racial trauma: integrating racial socialization into trauma-focused cognitive behavioral therapy for African American youth. Child Maltreat. 2021;26(1):17–27 (2020/05/05 ed).
Author information
Authors and Affiliations
Contributions
Author AR wrote the majority of the manuscript. Author's SF, EBH, and AS, wrote sections of the manuscript and reviewed the manuscript.
Corresponding author
Ethics declarations
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Competing Interests
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Rudrabhatla, A., Flowers, S., Becker-Haimes, E.M. et al. Centering Equity in the Implementation of Exposure and Response Prevention for Pediatric OCD: Current Evidence and Future Directions. Curr Dev Disord Rep (2024). https://doi.org/10.1007/s40474-024-00306-x
Accepted:
Published:
DOI: https://doi.org/10.1007/s40474-024-00306-x