Clinical Skills - Treatment Components and AMS-Ex Model

Question 1

Typical CBT Format

Answer 1

6-19 sessions of AMS (emotion identification; relaxation; cognitive strategies; psychoeducation), followed by 6-8 sessions of exposure to feared stimuli (Ale et al., 2015), typically conducted with child and involving parents at end of each meeting and separately in two parent-only sessions

93% of studies use AMS-Ex model (Reynolds et al., 2012), including CAMS (Walkup et al., 2008)

Question 2

Theoretical Importance of AMS

Answer 2

Ordering of AMS prior to exposure based on untested assumption it is required to change maladaptive cognitions (Crawley et al., 2012) or to tolerate exposure (Manassis et al., 2010)

AMS should be useful and that changes in anxiogenic thoughts crucial for improvement, according to CBT theory (Beck, 1976)

Question 3

Ale et al (2015)

Answer 3

Discussed link between more exposure practice and better outcomes for ADs posttreatment, and meta-analysis of 35 RCTs showed adding AMS and delaying exposures until after introduction of AMS doesn’t increase efficacy of exposure-based treatment

To understand which components necessary and sufficient for effective intervention, need dismantling studies, the ‘gold standard’ of investigating relative efficacy of treatment components - no dismantling studies at time of writing

Question 4

Peris et al (2015)

Answer 4

Assessed trajectories of change of 488 (7-17) in CAMS RCT (Walkup et al., 2008), showing that the introduction of both cognitive restructuring (a specific AMS) and exposure tasks significantly accelerated rate of progress on measures of symptom severity and global functioning moving forward in treatment, whereas introduction of relaxation limited impact

Younger participants appeared to benefit more, with steeper rates of improvement following implementation of exposure compared to adolescents - reports of impaired extinction learning in adolescence (although new supposed model is inhibitory learning; Craske et al., 2014), or perhaps lack of developmental appropriateness of study (but used C.A.T Project for adolescents; Kendall et al., 2002)

Question 5

Whiteside et al (2015) dismantling study

Answer 5

14 children (7-14) either 6 sessions of pre-exposure AMS found in traditional CBT, or parent-coached exposure therapy

At posttreatment, symptom change effect sizes superior effect of parent-coached exposure therapy, same at 3mo follow-up, suggesting introducing parent-coached EXP without AMS safe, tolerable, and distinguishable from initial sessions of standard CBT for CADs

Question 6

Whiteside et al (2020)

Answer 6

Meta-analysis of 75 RCTs comparing CBT to control treatment in 3-18-year-olds, showing generally typical AMS-Ex model but found (1) greater amount of in-session exposure related to significantly larger effect sizes between-groups; and (2) treatments that included relaxation associated with significantly smaller pre-to-posttreatment effect sizes between-groups

Encourage use of inhibitory learning theory of exposure (Craske et al., 2014) even though most of these habituation

Question 7

Bilek et al (2022)

Answer 7

102 (7-17) with range of primary ADs, with 12 sessions either EXP-focused CBT or relaxation mentoring training, involving parent involvement

EXP-focused CBT group 5.64x more likely as ‘much’/’very much’ improved on CGI-I scale

Question 8

Taylor et al (2021)

Answer 8

Qualitative feedback on exposure use in CBT shows much satisfaction, finding it the most helpful