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Clinical Case Studies

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DOI: 10.1177/15346501241253845
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in Youth: A Case Report

Daniel I. Gittins Stone1 , Mona P. Potter1, Hannah Doucette1,

Brianna Weissel1, and Kathryn D. Boger1

Abstract
Anxiety disorders and obsessive-compulsive disorder (OCD) are among the most common
mental health conditions in children and adolescents and are associated with various impairments
and long-term consequences. Evidence-based treatments exist but are often lacking in elements
needed to effectively treat youth with more severe presentations. This case report illustrates a
patient’s treatment course in an innovative program for children, adolescents, and young adults
with severe anxiety. The program offers a continuum of outpatient, evidence-based care tailored
to the severity of the patient’s condition. The case study focuses on “Jane,” an adolescent female
with anxiety as well as obsessive-compulsive spectrum disorders, who had previously received
extensive treatment without sustained improvement. Through the program’s three treatment
phases, Jane and her parents demonstrated consistent engagement and adherence to treatment.
Jane showed significant progress, with rapid reduction in symptoms and functional impairment.
This case report underscores key elements of this treatment that address gaps in traditional
approaches to care, particularly for patients with severe presentations, including the coordinated,
team-based approach; the continuum of evidence-based, phased treatment titrated to need; the
utilization of virtual individual, group and parent-focused care and between-session coaching to
enhance learning generalization; and the use of measurement-based care. Further research is
warranted to evaluate the generalizability and long-term outcomes of this program and its
potential to transform the treatment landscape for pediatric anxiety and OCD.

Keywords
anxiety, obsessive-compulsive disorder, children and adolescents, evidence-based treatment,
cognitive-behavioral therapy

1
InStride Health, Wellesley Hills, USA

Corresponding Author:
Daniel I. Gittins Stone, InStride Health, Inc., 396 Washington St, #266, Wellesley Hills, MA 02481-620, USA.
Email: [email protected]
2 Clinical Case Studies 0(0)

Theoretical and Research Basis for Treatment

Anxiety disorders and obsessive-compulsive disorder (OCD) are among the most common mental
health conditions affecting children and adolescents (Heyman et al., 2001; Merikangas et al.,
2010). They emerge early in life, increase in prevalence across development, and often exhibit a
chronic course (Copeland et al., 2014; Geller et al., 2021). They are associated with impairments
across multiple domains of development and functioning, including academic and social diffi-
culties, behavioral and emotional dysregulation, comorbid psychopathology, and suicidality
(Beesdo et al., 2009; Piacentini et al., 2003). Untreated, these disorders are associated with
progression to other behavioral health disorders, substance related disorders, and reduced quality
of life in adulthood (Kendall et al., 2004).
Cognitive-behavioral therapy (CBT) approaches, both with and without medication, have
shown efficacy in both weekly outpatient and brief intensive formats (Freeman et al., 2018; Higa-
McMillan et al., 2016). However, these treatments can be difficult for families to access, as the
demand for therapy continues to outpace supply (Eichstedt et al., 2024). Furthermore, wait times
for specialized psychological care can span multiple months (Moroz et al., 2020), which may
ultimately lead to the use of emergency room services instead of planned psychiatric care
(Radhakrishnan et al., 2022). Even when families are able to access care, few are able to access
evidence-based treatment for anxiety, with some estimates as low as 20% of youth receiving
treatment for anxiety disorders (Merikangas et al., 2011), and a more recent study indicating that
less than 3% of patients receive CBT in certain communities (Reardon et al., 2020). Similarly, the
average wait time for treatment can range from fifty days to almost a year even with insurance, and
is even longer for children with public insurance (Steinman et al., 2015). Contributing to the
problem, attending in-person therapy sessions can be logistically challenging, resulting in lower
session attendance rates and higher attrition rates within the first month, with attendance rates
typically ranging from 40% to 60% (Gopalan et al., 2010).
Youth with more severe presentations of anxiety and OCD, and those with more complex
diagnostic profiles (e.g., comorbid mood disorders), face additional challenges. They have higher
rates of mood and conduct disorders (Storch, 2008) and higher rates of suicidal ideation and
suicide attempts, when compared to their peers (Albert et al., 2019). They also present with
extensive functional impairment, including high avoidance of anxiety-provoking situations and
unhelpful parental accommodation behavior (Wu et al., 2016). These youth are also more costly;
direct (e.g., treatment) and indirect costs (e.g., missed school days and missed work days) quickly
spike as diagnostic severity increases (Pella et al., 2020). Furthermore, these youth often end up in
emergency rooms or inpatient units, which are costly and unsuited to adequately treat anxiety
disorders and OCD (Bushnell et al., 2019).
Unfortunately, youth with severe anxiety and OCD do not respond as well to CBT mono-
therapy, medication montherapy, or combination therapy compared to youth with less complex
presentations (Taylor et al., 2018). These youth demonstrate lower rates of remission, higher risk
for relapse in treatment, and may benefit from treatments targeting their specific diagnostic
presentations (Hudson et al., 2015). Evidence suggests that they often require additional support to
manage the distress and avoidance associated with their symptoms, comorbidities, and com-
plicating factors (Connolly et al., 2011). Research also indicates that short-term weekly CBT and
brief intensive treatments may often be inadequate in dosage (Storch et al., 2008) and lack the
necessary coordination between clinician, parents, and community partners, such as schools,
pediatricians, and other healthcare providers, needed to elicit treatment responses (Bitsko et al.,
2018). While intensive outpatient and partial hospitalization programs offer higher “doses” of
treatment, they also remove children and parents from their daily routines, which can limit both
access to anxiety and OCD triggers and generalization of the new learning.
Gittins Stone et al. 3

Though the practical utility and flexibility of weekly telehealth-based CBT and intensive
transdiagnostic approaches for the treatment of pediatric anxiety has been described in case studies
by Molino et al. (2022) and Hudson et al. (2022) respectively, and while intensive telehealth-based
CBT with medication management has been demonstrated to have outcomes commensurate with
in-person treatment for pediatric anxiety and OCD (Gittins Stone et al., 2023), there remains a
dearth of information about the use of phased, telehealth-based, transdiagnostic, coordinated care
models for the treatment of severe pediatric anxiety and OCD. This case report illustrates a
patient’s journey through an innovative, newly-developed treatment program for children, ad-
olescents, and young adults with anxiety and/or OCD. Though the program treats patients with
anxiety and OCD across the full spectrum of acuity, it is uniquely designed to meet needs of
patients with moderate to severe presentations on an outpatient basis. It weds an evidence-based
treatment approach developed over the past decade at an academic psychiatric hospital with
structural, operational, and technological enhancements to offer care that is accessible and ef-
fective. Rooted in a transdiagnostic approach, this treatment draws primarily from CBT, em-
phasizing exposure therapy, cognitive restructuring, and identifying and tolerating emotions (See:
Clark & Beck, 2011; Craske et al., 2014). It also incorporates elements of Acceptance and
Commitment Therapy (ACT), integrating values-based motivation exercises, mindfulness, and
cognitive defusion through activities such as values identification, choice point and dropping
anchor, and defusion exercises (See: Hayes et al., 2011). Additional mindfulness concepts, in-
cluding “What and How” skills, and states of mind from Dialectical Behavior Therapy (DBT)
complement the therapeutic framework to help patients cultivate self-awareness and the practice
of sitting with emotions (see: Linehan, 1993) in order to facilitate engagement in exposures and
values-consistent behaviors. In addition to the transdiagnostic curriculum that all patients in the
program use, additional, supplemental modular materials are available for patients targeting
complicating factors that may require more specialized interventions (e.g., school avoidance or
suicidal ideation and self-harm). To enhance “surround sound” and social learning, parent
guidance groups, patient skills groups, and presentation-specific exposure groups are also offered
as part of the program. Measurement-based care is employed to gather baseline information
related to levels of symptoms and functioning upon admission and to track and address changes
throughout treatment.
The program was designed to address existing shortcomings in the treatment of pediatric
anxiety and OCD, particularly for youth with more severe presentations, including the lack of: (1)
coordinated care; (2) flexibility in treatment dosage based on patient acuity and need; (3) op-
portunities for learning generalization and between session support; and (4) data-driven decision-
making as part of care. All treatment sessions are conducted virtually in effort to reduce barriers to
care. Treatment consists of three phases, varying in duration and intensity according to the
patient’s severity upon admission. Typically, treatment lasts between four and 12 months, with
Phase 1 involving the highest level of intervention, followed by gradual reduction in intensity in
Phases 2 and 3, respectively. Each patient is paired with a treatment team including a licensed
therapist, an exposure coach, and a licensed child and adolescent psychiatrist.

Case Introduction
“Jane” (pseudonym) is a white, late adolescent female seen at a virtual therapy program designed
for the treatment of pediatric anxiety and OCD. Jane presented with treatment refractory specific
phobia of vomiting, ARFID, panic disorder, agoraphobia, excoriation disorder, subthreshold
OCD, and elevated symptoms of depression. She was chosen for this case report due to the
complexity of her presentation that entailed multiple co-occurring diagnoses and high levels of
functional impairment including difficulty leaving her house, as well as her previous participation
4 Clinical Case Studies 0(0)

in treatment at both outpatient and higher levels of care without sustained relief. This case study
demonstrates the complexity of Jane’s presentation and underscores the role of the distinct care
elements provided in this program in facilitating notable improvements in her symptoms and
functioning.
Data were collected from medical records and chart review, which encompassed a wide range
of clinical information. The case report presented in this study was determined to be exempt from
formal review by the Institutional Review Board (IRB) of record. The exemption was granted
based on the nature of the study, which involved a review of existing records and psychological
measures given as standard care. Jane and her father provided consent for the use of their
anonymized information in this study. A pseudonym was used, and demographic features, other
than race, biological sex and developmental range (e.g., late adolescent) were omitted for the
purpose of maintaining patient confidentiality.

Presenting Complaints
Jane was admitted to this program with multiple presenting complaints and with a longstanding
history of anxiety and obsessive-compulsive (OC) spectrum disorders, dating back to her early
childhood. Her primary reported concerns at admission were fears of becoming sick and vomiting
as well as obsessions related to contamination, which had recently resulted in restricted eating,
medically significant weight loss, and multiple hospitalizations (detailed in history below). These
fears and associated avoidant behaviors were reported to have precipitated early in life, then
further perpetuated the year prior to the present admission when Jane experienced multiple
physical illnesses that involved vomiting. At the time of her admission, Jane had limited her food
intake to specific cereals, berries, nuts, and some proteins, such as chicken soup and beef jerky.
She reported anxiety related to eating a multitude of other foods, such as other fruits, vegetables,
meats, pizza, hamburgers, and Mexican food, fearing that they would make her vomit. Addi-
tionally, she reported difficulty drinking water or eating quickly, eating food without previously
checking its temperature, and eating at restaurants or other public locations. Jane also reported
symptoms of panic and agoraphobia, which, coupled with her fears of becoming sick, led to social
isolation, difficulty completing academic work, and participating in extracurricular activities,
elevated symptoms of depression, and low levels of hope and life satisfaction. She also disclosed
compulsive skin picking directed at her feet, which had made it painful and difficult for her
to walk.

History
Jane lived at home with her parents and siblings and was reported to have positive family re-
lationships. She was reported to have close friends and denied experiencing bullying at school.
Jane reported having missed 20 days of school and arrived late or left early 30 times during the
previous school year and was currently attending an online school. Though she had previously
enjoyed outdoor activities and had had a job at a local shop, she reported that she had stopped these
activities due to her recent increase in anxiety and avoidance. Jane denied a history of traumatic
stress, family history of mental illness, developmental delay, substance abuse history, racism/
discrimination, and food or housing instability. Prior to admission to this program, Jane had
participated in multiple rounds of weekly outpatient therapy off and on over eight years, the
specific modality of which was not reported. Approximately five years prior to her participation in
this program, Jane had participated in an intensive outpatient treatment program (IOP) spe-
cializing in the treatment of anxiety and obsessive-compulsive disorder using cognitive-
behavioral therapy with exposures, which initially reduced her symptoms. However, in the
Gittins Stone et al. 5

year preceding admission to this program, Jane experienced heightened fears of illness, leading to
food restriction and significant weight loss, losing over ten pounds in one week. As a result, she
had spent three nights in an emergency room, followed by a ten-day hospitalization for medical
stabilization, and then seven days in residential care focusing on weight gain and medication
management. Following her hospitalization, she returned to the same IOP for a six-week ad-
mission; however, she struggled to maintain progress despite extensive intervention at all levels
of care.

Assessment
Jane’s level of acuity was assessed during a phone intake session, using a standardized set of
criteria. Jane met criteria for severe presentation based on several factors: (1) level of functional
impairment and distress as well as psychiatric comorbidities and medical complexities, (2)
treatment history, and (3) complicating factors (e.g., recent history of school avoidance). She
presented with five psychiatric diagnoses and two subthreshold mood and obsessive-compulsive
spectrum illnesses. Jane demonstrated substantial impairment across various life domains, par-
ticularly in social and work settings, and had a history of prior medical and psychiatric hospi-
talizations and outpatient therapy.
At the time of Jane’s admission, 65 patients had enrolled in the program. Among them, 35%
(n = 23) were classified as severe, 45% (n = 29) as moderate, and 20% (n = 13) as mild. On
average, patients in the severe category had been diagnosed with three to four psychiatric disorders
(mean = 3.83, SD = 1.83). Factors assessed as part of the severity algorithm for this program
include functional impairment or distress, presence of psychiatric comorbidities, indicators of risk,
presence of medical complexities, recent psychiatric ER visits, higher levels of care, prior rounds
of outpatient therapy, participation in therapeutic school, family-related challenges, school
avoidance, motivation for treatment, abuse or neglect, and social determinants of health such as
poverty, discrimination, parental unemployment, and housing or food instability.
Jane and her family participated in a diagnostic evaluation conducted by her program therapist.
Measurement-based care was administered throughout this program, which involved regularly
administering psychological measures and collaboratively using outcomes data to inform
treatment (see Table 1 for detailed measure information). At admission, Jane’s self-report data
indicated clinically elevated symptoms of anxiety and functional impairment (GAD-7 = 10; SFSS-
I = 98th percentile; OASIS-Y = 14), as well as clinically elevated symptoms of depression (PHQ-
9-A = 14). Jane scored in the low range on measures of life satisfaction (BMSLSS-PTPB = 10th
percentile) and hope (CHS-PTPB = 8th percentile). Jane’s parents also presented with moderate to
high levels of parental accommodation (FASA = 24) and elevated levels of parent strain (CGSQ-
SF7 = 73rd percentile). At admission, Jane had been prescribed the following psychiatric
medications by her outpatient physician: sertraline 150 mg per day, hydroxyzine 50 mg nightly,
olanzapine 2.5 mg nightly, and propranolol 10 mg as needed. While in treatment, these medi-
cations were monitored by her program psychiatrist, in coordination with her outpatient provider.
Jane was also reported to be taking supplements, which were self-managed by the family. She had
weekly weigh-ins with her pediatrician, and weekly meetings with a dietitian. Her weight was
reported to be trending upward at admission, though her calorie intake was suboptimal.

Case Conceptualization
Based on Jane’s and her parent’s reports during the clinical evaluation, Jane’s anxiety emerged
early in life and persisted over time. Although no family history of anxiety was reported, it is
possible that her early onset of symptoms indicated a genetic or temperamental predisposition to
6 Clinical Case Studies 0(0)

Table 1. Summary of Psychological Measures.

Number of Clinical
Name and Reference Domain Items Range Cutoff

Generalized anxiety disorder scale - 7 Anxiety symptoms 7 0–21 Minimal: 0–4

(GAD-7; Jordan et al., 2017; Spitzer Mild: 5–9
et al., 2006) Moderate:
10–14
Severe: 15–
21
Overall anxiety severity and Anxiety symptoms, 7 0–28 None
impairment scale - youth (OASIS-Y; intensity and functional
Comer et al., 2022) impairment
Patient health questionnaire - Depression symptoms 9 0–27 Minimal: 0–4
9 adolescent (PHQ-9-A; Richardson Mild: 5–9
et al., 2010) Moderate:
10–14
Mod sev.:
15–19
Severe: 20–
27
Family accommodation scale - anxiety Parent-report 13 0–52 None
(FASA; Lebowitz et al., 2013) accommodation
Symptom function and severity scale - Internalizing symptoms 14 Percentile Low: <25th
internalizing (SFSS-I; Bickman et al., (e.g., anxiety and Medium:
2010) depression) 25th-75th
High: >75th
Children’s hope Scale-PTPB (CHS- Hope 4 Percentile Low: <29th
PTPB; Bickman et al., 2010) Medium:
29th-79th
High: >79th
Brief multidimensional students’ life Life satisfaction 6 Percentile Low: <31st
satisfaction scale - PTPB (BMSLSS- Medium:
PTPB; Bickman et al., 2010) 31st-79th
High >79th
Caregiver strain questionnaire short- Parent-report caregiver 7 Percentile None
form (CGSQ-SF7; Bickman et al., strain
2010)

anxiety disorders. The origin of Jane’s anxiety, particularly related to the fear of vomiting, was
reported to have been precipitated by an event in second grade when she witnessed a classmate
vomit. Distorted cognitions, predominantly centered around fears of illness, and the belief that she
would be unable to seek help if sick, contributed to her early anxiety and the beliefs that the world
was unsafe or that she would be incapable of caring for herself if sick. In the year prior to her
current admission, Jane experienced multiple viral illnesses, one of which led to vomiting. These
more recent experiences and associated thought patterns led to a cascade of symptoms, including
intrusive fears of getting sick, heightened awareness of physiological sensations in her stomach,
panic symptoms, and behavioral restrictions such as limiting food intake (both quantity and type),
avoiding school and public places, and resulting low mood. Additionally, according to parent
reports and results from measurement-based care self-report measures, Jane’s parents frequently
provided reassurance related to her worries and engaged in behaviors that facilitated her
Gittins Stone et al. 7

avoidance, such as adjusting the family schedule and activities to accommodate her avoidance of
anxiety-provoking situations and stimuli.
Jane’s avoidant behavior and distorted cognitions, along with her parents’ well-intended
accommodation, were hypothesized to contribute to a self-perpetuating cycle of negative rein-
forcement. More specifically, when faced with anxiety-inducing stimuli, such as encountering
new foods or leaving the house, Jane experienced distress and engaged in avoidance, which
temporarily alleviated her distress, but ultimately reinforced her avoidant behavior, distorted
thinking, and negative intermediate and core beliefs.
Notably, Jane presented with several protective factors, including a high willingness to engage
in treatment, good insight, and committed parents. Treatment goals were for Jane to regain
functioning, enabling her to participate in social events, travel outside the home, and spend time
with family and friends. To achieve these goals, considering the identified predisposing, pre-
cipitating, perpetuating, and protective factors, it was recommended that Jane and her family
engage in a multi-pronged treatment approach within the program: (1) individual and group CBT
targeting anxious avoidance and cognitive distortions; (2) parent training to reduce accommo-
dation of anxiety behaviors and promote the reinforcement of brave behaviors; (3) exposure
coaching and between-session coaching to increase the frequency of exposures and enhance
generalization of learning; (4) measurement-based assessment of progress; and (5) continued
medication management and consultation with external healthcare providers.

Course of Treatment and Assessment of Progress

Treatment Overview
Jane completed this virtual treatment program designed to treat children, teens, and young adults
with anxiety and OCD across the severity spectrum. Her program therapist provided the diagnostic
and clinical evaluation, treatment planning, family work, and skills training. Jane’s exposure
coach facilitated treatment engagement through motivation building exercises and by helping Jane
practice exposures to support learning generalization in her day-to-day life. Her exposure coach
was also available for between-session coaching, both proactively and reactively, in the form of
scheduled HIPAA-compliant messages, along with reactive texts and phone calls. The psychiatrist
oversaw medication management and medical complexities, working closely with Jane’s therapist
and exposure coach to track her progress and medication needs. The psychiatrist also coordinated
with her pediatrician to ensure ongoing monitoring of her eating habits, weight, and overall
physical health.
Throughout treatment, care coordination with Jane’s family and school was conducted by the
therapist through virtual live sessions and phone calls, and coordination with the pediatrician and
nutritionist was conducted by the psychiatrist to ensure treatment gains and in order to “activate
the environment” for sustained ongoing support beyond the treatment episode. Internal care
coordination between the therapist, psychiatrist, and exposure coach occurred during weekly
rounds and treatment planning sessions, as well as through asynchronous communication through
a HIPAA-compliant proprietary application.

Phase 1. The initial intensive treatment phase, which was 12 weeks in duration for Jane, began
with a diagnostic interview and then focused on skill acquisition. This phase of care emphasized
the onset of exposures within the first three weeks of treatment. Jane met for weekly 50 minute
sessions with her therapist, twice-weekly 30 minute sessions with her exposure coach, and
monthly 30- to 50-min sessions with her psychiatrist. Along with individual sessions, Jane
participated in weekly skills groups for skill building practice. Jane’s parents participated in
8 Clinical Case Studies 0(0)

separate parent guidance group sessions with a focus on increasing validation and decreasing
parent accommodation. These group sessions were run by program therapists.
Jane entered treatment with an understanding of CBT principles, such as cognitive re-
structuring and exposure techniques, from her previous experiences in an IOP. During this initial
phase of the program, Jane was engaged in psychoeducation and skills practice related to values-
based decision making, cognitive defusion, mindfulness, and tolerating distress. Jane collaborated
with her therapist to develop multiple fear and avoidance hierarchies targeting emetophobia,
agoraphobia, panic, and food aversion (see Table 2). These hierarchies guided her exposure
practices, which were conducted both at home and in community settings. For example, to

Table 2. Fear and Avoidance Hierarchies Across Treatment Targets.a

Restricted Food
SUDS Emetophobia Agoraphobia Panic Intake

10 Watch videos of vomit and Eat at previously

then leave house forbidden
restaurant;
Eat meat sauce only
9 Watch videos of vomiting in Use public restroom Straw breathing; Eat food without
the bathroom; checking
Make fake vomit Run in place; temperature;
Shake head; Eat previously
Spin in place; forbidden food
8 Listen to sounds of vomiting Go to doctors office Eat pasta with meat
sauce;
Eat medium rare
burger;
Drink half a glass of
water in
30 seconds
7 Spit into toilet Drink milk-based
drink at coffee
shop;
Eat spaghetti
Drink full glass of
water in one sitting
6 Watch a video of someone Go to the shopping Write about going
vomiting center with parent into restaurant;
(1 hour) Eat a well done
burger;
Drink half a glass of
water in 1 minute
5 Watch video of someone Go to coffee shop and Breathe quickly/ Drink tea;
pretending to vomit order favorite drink hyperventilate Eat banana
before eating
4 Watch video of someone Go to the shopping Prepare a meal;
pretending to vomit center alone Eat penne pasta;
(10 minutes) Drink half glass of
water in one sitting
3 Watch a cartoon of vomit Walk around the Eat specific pasta
neighborhood alone
a
Does not include all exposures completed during treatment.
Gittins Stone et al. 9

confront her fear of vomiting, she gradually exposed herself to stimuli such as cartoon videos of
vomiting, then realistic videos of people vomiting, and then she made fake vomit at home. To
address her food restriction issues, Jane worked with her exposure coach to categorize foods by
perceived risk levels (“safe,” “mildly risky,” “risky,” and “unsafe”). She practiced eating in-
creasingly challenging foods in different environments, which also served to address contami-
nation fears. In coordination with her team psychiatrist and outpatient providers, the therapist and
exposure coach helped to reinforce the use of Jane’s meal plan that was created by her outside
nutritionist. Her psychiatrist and therapist provided a feedback loop to external partners about her
progress through this phase.
To address her panic symptoms, Jane participated in interoceptive exposures, which involve
simulating sensations associated with panic attacks. Additionally, to target agoraphobia, she
completed community-based exposures to gradually reintegrate into activities out in the world that
she had once enjoyed but had avoided due to panic, such as visiting the mall, going to coffee shops
and restaurants, and spending time with friends. Initially she was accompanied by a parent during
these exposures, but, over time, she progressively spent more time away from home on her own
and even attended driving school. Of note, in addition to targeting anxiety, community-based
exposures also served as behavioral activation targeting symptoms of depression, enabling Jane to
get out of the house and engage in mood boosting activities out in the world. To target excoriation
disorder, Jane learned to recognize and articulate her thoughts, emotions, and physical sensations
before, during, and after engaging in skin-picking behaviors, in order to bring awareness to the
behavior. She also developed a list of competing behaviors to practice while resisting the urge to
engage in skin picking.
Throughout Phase 1, Jane reached out to her exposure coach in moments of distress, such as
when she had difficulty leaving her house. During these texts and calls, she was able to practice
real-time strategies, such as dropping anchor, in order to engage in actions that aligned with her
values and goals. The real-time practice of these skills in moments of distress provided a sharp
contrast to her former learned behaviors, including avoiding her emotions and triggers. Jane also
received motivational and encouraging text messages from her exposure coach related to exposure
practice and treatment victories, in order to help her maintain momentum.
Due to Jane’s complex medical presentation related to her restricted food intake, she had
monthly virtual appointments with her psychiatrist during Phase 1. These sessions were utilized to
evaluate her overall health, make any necessary adjustments to her medication regimen, assess the
effects of medication changes, monitor medication adherence, and ensure compliance with her
treatment plan. Additionally, these appointments provided an opportunity for the psychiatrist to
collect information to share with external healthcare providers. After consulting with Jane, her
family and her outpatient medical team, the psychiatrist discontinued olanzapine during this phase
in care as it was deemed no longer necessary. The hydroxyzine dose was also reduced from 50 mg
to 25 mg, and the frequency was reduced from nightly to as needed.

Phase 2. Consistent with Jane’s progress by this point in care, the intensity of her treatment was
reduced in Phase 2 with a focus on learning generalization. Phase 2 included weekly 30-min
sessions with her therapist, weekly 30-min sessions with her exposure coach, and sessions with
her psychiatrist at a reduced frequency. Initially, Jane’s treatment plan included spending eight
weeks in Phase 2; however, it was decided that she should extend her time in this phase for one
additional week due to a scheduled program closure for a holiday break. In Phase 2, Jane focused
on practicing her virtual exposures in various settings in the community, using a portable device.
This meant that she could participate in in vivo exposures in her neighborhood and community
while receiving coaching from her exposure coach and her therapist. Jane passed driver’s
10 Clinical Case Studies 0(0)

education class and her driver’s test, was spending time with friends in the community, and was
eating with fewer restrictions.
Jane’s parents participated in an ongoing parent practice group to receive support and guidance as
they continued to reduce accommodations and apply new parenting skills. Between-session coaching
was available to Jane on an as-needed basis, which she used in the event that she felt overwhelmed and
needed help engaging in an exposure. Jane met with her psychiatrist twice during this phase of
treatment, as her weight was stable and no adjustments to her medications were indicated.

Phase 3. The intensity of treatment was further reduced in Phase 3 as Jane continued to make
progress. The third phase, which lasted 20 weeks for Jane, focused on relapse prevention and
helping her and her parents to solidify the strategies they had learned so that they could become
enduring habits. Jane continued to engage in weekly 30 minute coaching sessions, whereas
therapy sessions were reduced to once-a-month to review treatment progress and planning. She
continued to utilize on-call support, though infrequently, when she was preparing for difficult
in vivo exposures. Throughout this phase, Jane consistently demonstrated her commitment to the
exposure-based approach and a willingness to make exposures part of her everyday life. She
continued to participate in measurement-based care assessments, and the team used the data to
help identify and address potential setbacks in order to prevent relapse. Jane met with her
psychiatrist twice during this final phase of treatment, and no medications were adjusted.

Assessment of Progress
Treatment progress was measured through both qualitative and quantitative data. Jane demon-
strated strong engagement and attendance. She attended approximately 91% (32 of 35) of in-
dividual and family therapy sessions, 100% (8 of 8) of psychopharmacological sessions, 63% (5 of
8) of skills groups, and 90% (28 of 31) of scheduled coaching sessions. Her parents attended 100%
(22 of 22) of their parent guidance and practice groups.
Jane experienced a rapid reduction in anxiety, obsessive-compulsive, and depressive symptoms
that continued through the three phases of care. She also experienced significant improvements in
functional impairment. By the end of treatment, she had gained employment, was able to tolerate
multi-day trips away from home, had gotten her driver’s license, and remained fully engaged in
her classes. Her food intake stabilized and remained stable throughout the remainder of treatment.
Jane’s psychiatric medication regimen remained stable, with one medication having been dis-
continued (olanzapine), and the dosage and frequency of another reduced (hydroxyzine from
50 mg to 25 mg) in Phase 1 of treatment. Self-report assessments indicated a significant reduction
in symptoms of anxiety and depression, with scores reaching minimal levels (see Figure 1; GAD-
7 = 4; PHQ-9-A; = 4 SFSS-I = 13th percentile). There was also a notable decrease in anxiety
symptom severity and functional interference (OASIS-Y = 6, 57% reduction). Jane reported
higher levels of life satisfaction and hope, as evidenced by increased scores on corresponding
scales (BMSLSS-PTPB = 98th percentile; CHS-PTPB = 79th percentile). Furthermore, her
parents reported a substantial decrease in parent accommodation (FASA = 11), indicating im-
proved family dynamics. There was also a significant reduction in parent strain, indicating
decreased parental emotional distress, and less interference with work and daily activities (CGSQ-
SF7 = 24th percentile).

Complicating Factors
At admission, Jane presented with multiple comorbid diagnoses and complicating factors, in
addition to her anxiety and subthreshold OCD, including ARFID, excoriation disorder, depressive
Gittins Stone et al. 11

Figure 1. Varying measurement lengths are due to cadence and missing data. Vertical lines indicate
treatment transitions.

symptoms, and a recent history of school avoidance. Despite previously undergoing multiple
rounds of care involving both psychological and psychiatric interventions, Jane had continued to
experience non-remitting symptoms of anxiety, depression, and OC-spectrum disorders prior to
receiving care in this program. This contributed to her functional impairment, including difficulty
leaving her house, engaging socially, and keeping a job, which ultimately led to her admission to
the program. Additionally, her constellation of symptoms, revolving around the fears of illness,
12 Clinical Case Studies 0(0)

vomiting, and contamination, manifested in a pronounced restriction in food intake and significant
associated functional impairment. While medically stable at the initial assessment, she neces-
sitated ongoing medical monitoring to ensure appropriate calorie consumption and weight sta-
bility, which was performed by her in-program psychiatrist in coordination with her external
medical provider.

Access and Barriers to Care

Accessing appropriate care for youth with anxiety and OCD can prove challenging due to various
barriers. Weekly outpatient and brief intensive care can be insufficient for individuals with
complex cases (Storch et al., 2008). Furthermore, there is a paucity of CBT with ERP programs
(Reardon et al., 2020), and wait times for specialized psychological care are lengthy (Moroz et al.,
2020). The treatment program in which Jane participated aims to address these issues by providing
accessible, intensive services with a coordinated, systems-based approach. Jane was able to be
seen for her initial therapy session within two weeks of seeking services, and treatment sessions
occurred virtually which further enhanced accessibility for her and her family.

Follow-Up
Jane’s progress was systematically monitored across various domains of symptoms and func-
tioning using self-report and parent-report measures throughout the entirety of treatment, em-
ploying a measurement-based care approach. The frequency of specific measures varied based on
recommended administration schedules but was consistently applied throughout all phases of
treatment. Jane actively participated in reviewing these measures with her therapist, contributing
valuable insights to discussions about progress and treatment planning. As noted above, Jane
responded positively to treatment, as evidenced by the notable reductions in symptom severity,
functional impairment, parent accommodation, and parent strain. These improvements, initially
observed at the beginning of treatment, persisted consistently across all phases of the intervention.
Additionally, Jane was contacted following one year post-Phase 1 of treatment, at which point, she
reported that she had remained out of the hospital, continued to enjoy her life, and had recently
traveled to other states on her own.

Treatment Implications of the Case

This case report illustrates a novel approach to the treatment of an adolescent with severe anxiety
using an evidence-based, integrated virtual treatment program. Jane demonstrated significant
treatment gains across three phases of care that allowed for a gradual shift from reliance on her
clinical team to self-reliance with parental and community (school, pediatrician) support. Key
elements of Jane’s care highlighted through this case report are: (1) the comprehensive and
coordinated care team approach; (2) the continuum of evidence-based, outpatient care, that is
titrated based on acuity at admission and treatment response; (3) the utilization of virtual in-
dividual, group and parent-focused care and between-session coaching to enhance learning
generalization; and (4) measurement-based care to help guide treatment and ensure transparency
in care.
The coordinated approach to care, including therapy, coaching, and psychopharmacology,
ensured that Jane received the personalized and integrated care necessary for her complex and
severe presentation. Therapy served as an educational and interventional foundation for Jane and
her family, helping them to better understand and manage anxiety and OCD symptoms with
implementation of exposure plans and skills usage. Coaching helped Jane engage in exposures
Gittins Stone et al. 13

and generalize the learning in “real time” with between-session availability that allowed for
support with unplanned exposures and real life stressors. The psychiatrist worked closely with the
therapist, exposure coach, and outpatient pediatrician in order to optimize medication-related
interventions and planning to ensure that the family was receiving “surround sound” messaging.
This wrap-around, coordinated approach allowed for multiple providers to operate at the top of
their license with a consistent message and method.
The continuum of three phases of care allowed for Jane to receive intensive services at the
outset with a gradual service taper over the course of treatment. The goal was to help Jane shift out
of “patient” mode and into “student,” “friend,” and “employee” mode by helping her gain strength
and confidence in her ability to manage emotions and engage in life according to her values, thus
increasing her chances of sustained post-treatment gains. The multiple treatment touchpoints,
including individual therapy and skills groups, that Jane received during the initial phase of the
treatment facilitated momentum; sessions with her exposure coach and therapist allowed for her to
build a foundation of skills and strategies and to practice exposures throughout the week. The
initial, more intensive phase was time-limited, and Jane’s treatment supports were gradually
reduced through the second and third phases, corresponding with her demonstration of acquired
and implemented skills, progress with exposures, and decreased avoidance. The third phase
allowed Jane to receive support from her exposure coach for ongoing skill and exposure practice,
with as-needed therapy appointments. The goal of the third phase was to reduce risk of relapse and
re-initiation of costly treatment services, which may be especially important for individuals with
severe symptoms who are at greater risk for relapse due to high intensity of symptoms and
functional impairment (Scholten et al., 2013). The gradual reduction of supports throughout
treatment corresponded with Jane’s and her parents’ demonstration of increased autonomy,
confidence in skill usage, and feelings of empowerment in skills practice.
For many youth with more severe presentations, treatment in a therapy “bubble” without
extension into daily life may limit treatment impact, generalization, and post-treatment symptoms
reduction and functional improvement (Manassis et al., 2014). Similar to Jane, these youth are
more likely to require support outside of sessions to manage the distress and avoidance associated
with symptoms of their anxiety or OCD such as family, community, and school supports and
parental training (Connolly et al., 2011), and this support may be limited in weekly outpatient CBT
or ERP models. Additionally, youth with severe anxiety and/or OCD require further support to
manage comorbidities and complicating factors such as depressive mood, suicidal ideation,
obesity, and family conflict (Bitsko et al., 2018). The between-session coaching that Jane received
during care was aimed at generalizing the skills she had learned in skills groups and preventing the
escalation of symptoms and in-the-moment distress that could otherwise have resulted in ER visits
or costly higher levels of care. Jane effectively used between-session coaching to practice new
learning; with her exposure coach, she learned to tolerate moments of high anxiety and to lean into
the fear instead of avoiding it. Notably, the frequency of Jane’s usage of between-session coaching
decreased over the course of treatment as she internalized the messages from her exposure coach,
learned to coach herself in moments of distress, and requested less support. Additionally, virtual
therapy allowed for Jane to do exposures in the community, with support of her therapist and
coach, that could have been harder to target in traditional in-office therapy. Jane’s parents also
actively participated in the virtual parent groups aimed at equipping them with the necessary tools
to support Jane throughout treatment and as she resumed her daily routines. The virtual nature of
these groups made them more accessible to the family, allowing them to attend regularly and
receive guidance and support in reducing accommodation and encouraging Jane to engage in
exposures and take steps toward facing her fears in her daily life.
This case also highlights the significant role of measurement-based care in guiding the ap-
proach used in Jane’s treatment. In traditional approaches to therapy, outcomes are rarely tracked
14 Clinical Case Studies 0(0)

over the course of treatment (Lewis et al., 2019). This contributes to the idea of “therapy as a black
box” and inhibits the ability of clinicians to make data-driven decisions. Throughout the three
distinct phases of Jane’s treatment in this program, measurement-based care served as a tool to
systematically assess Jane’s progress, treatment response, and the ongoing need for intervention
adjustments. Also, by reviewing measurement results with Jane, measurement-based care served
as another avenue for Jane and her family to take an active role in treatment planning, and this
provided a feedback loop to increase their willingness to continue completing assessments.

Recommendations to Clinicians and Students

This case report demonstrates the course of treatment and outcomes of one patient participating in
an innovative model of treatment and aims to present clinicians and students with the practical
methods used to treat individuals with complex presentations of anxiety, obsessive-compulsive
spectrum, and comorbid mood-related illnesses within this program. These include using a
coordinated team-based approach; a continuum of phased treatment titrated to need; virtual
individual, group and parent-focused care and between session coaching; and measurement-based
care. While recognizing the inherent limitations of a single case study—such as a lack of
generalizability and the increased potential for bias—the observed successes warrants thoughtful
consideration for the broader examination of this innovative intervention. Future research en-
deavors should prioritize larger samples, employ more rigorous experimental designs, and
specifically investigate the implementation of this intervention across diverse patient populations.

Acknowledgments
The authors extend sincere gratitude to Jane and her parents for sharing their experiences through this report.
We would also like to express our appreciation to the dedicated members of Jane and family’s clinical team
who supported her treatment by providing direct care. Their collaborative efforts greatly enhanced the overall
quality of the care provided.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship,
and/or publication of this article: To maintain transparency and integrity, we wish to declare the following
potential conflicts of interest with respect to the research, authorship, and/or publication of this article:
1. Mona Patel Potter, MD is the sole owner of InStride Health, MA PC. She is a co-founder and Chief
Medical Officer of InStride Health, Inc. and holds equity in the company. Dr. Potter is a clinical advisor to
Mirah Inc., a company providing Measurement-Based Care functionality, and is also the spouse of a Mirah
co-founder who has equity.
2. Kathryn Dingman Boger, PhD, ABPP is a co-founder and Chief Clinical Officer of InStride Health, Inc.
and holds equity in the company. Dr. Boger is also a clinical advisor to Mirah Inc., for which she holds equity.
3. Daniel Ian Gittins Stone, PhD, is an employee of InStride Health MA PC and InStride Health Inc., and
holds stock options in the company.
4. Hannah Doucette, PhD, is an employee of InStride Health MA PC and InStride Health Inc., and holds
stock options in the company.
5. Briana Weissel is an employee of InStride Health MA PC.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Gittins Stone et al. 15

ORCID iD
Daniel I. Gittins Stone  https://orcid.org/0000-0002-3035-9634

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Author Biographies
Daniel Ian Gittins Stone, PhD is a licensed psychologist. He is the Director of Digital Health
Innovation at InStride Health, a Psychologist at McLean Hospital, and an instructor at Harvard
Medical School. He utilizes and conducts research on evidence-based treatments for anxiety,
obsessive compulsive spectrum, and related disorders among children, adolescents, and young
adults.
Dr. Mona Patel Potter is board-certified child and adolescent psychiatrist. Dr. Potter has served as
the Medical Director of McLean Hospital’s Child and Adolescent Outpatient Services and co-
developed several programs, including the McLean Anxiety Mastery Program (MAMP) and
McLean School Consultation Service. Dr. Potter is a co-founder and Chief Medical Officer of
InStride Health.
Hannah Doucette, PhD is a licensed psychologist and therapist at InStride Health. She completed
her clinical internship at the Alpert Medical School of Brown University, and has extensive
experience working with children, adolescents, and their families in intensive treatment settings.
Brianna Weissel, BS, is a clinical research assistant at InStride Health. She is interested in child
and adolescent psychology, specifically anxiety treatment. She is going to pursue her PhD in
clinical psychology with a focus on anxiety and family and sibling relationships.
Kathryn Dingman Boger, PhD, ABPP is a board-certified child and adolescent clinical psy-
chologist who has devoted her career to helping children and teens with anxiety and Obsessive-
Compulsive Disorder (OCD). In 2013, she co-developed the McLean Anxiety Mastery Program
(MAMP) at McLean Hospital where she served as Program Director. In 2021, Dr. Boger co-
founded InStride Health with the mission of increasing access to insurance-backed, evidence-
based care for children, adolescents, and young adults with anxiety and OCD.