Exposure-Based Program Sees Strides in Treating Childhood Anxiety and OCD

By Matt Phillion

A recent outcomes report has found strong data on reductions in symptoms of anxiety and depression in young patients. The approach uses a tailored approach to treating children with moderate to severe anxiety and/or OCD using true cognitive behavioral therapy with a focus on exposures.

Pediatric mental health provider InStride Health assigns a multidisciplinary team of a therapist, psychiatrist, and an exposure coach to deliver care through an entirely virtual model to help support their patients as they face their fears in everyday, real-world situations and moments.

The program focuses on patients with anxiety and OCD ranging from 7 to 22 years of age. In InStride’s recent outcomes report, looking at data from 2022 to 2024, they found that 98% of program graduates experienced an overall improvement compared to baseline. In addition, the report found that:

• Nine out of 10 reported reduction in anxiety symptoms, with significant reductions observed as early as two months into the program
• Nine out of ten reported reduction in depression symptoms
• 92% showed “much” or “very much” improvement
• 0% of patients were hospitalized at 12 months post discharge

“We’ve seen remarkable outcomes,” says Kathryn Boger, PhD, ABPP, co-founder and chief clinical officer with InStride Health. “Some of these patients weren’t attending school, weren’t socializing because of the severity of their anxiety or OCD and they had not found relief from previous treatments.”

“Most importantly, they got their lives back,” says Boger. “We want kids to be kids, to be active in school,” she says. “Anxiety and OCD get in the way of things they love and that matter to them. We’re trying to get those things back on track. We want them living their full lives and making decisions based on what matters to them.”

InStride Health is a heavily exposure-based program that includes therapy, coaching, and medication management. The model was initially developed as an in-person model at McLean Hospital, Harvard Medical School, and it drew patients from all over the country and the world. During COVID, they moved from in-person to fully virtual and found the outcomes between in-person and virtual were equivalent.  In addition, virtual allowed for even more flexibility for the families and for doing exposures in the community. Then, importantly, they had the opportunity to scale the model and InStride Health was born.

“We have been able to scale the model virtually, doing exposures in the real world,” says Boger. “Young people are able to go to schools, neighborhoods, restaurants, and have their provider in their ear coaching them through the exposures. It allows us to meet the need for all kids and it affords more flexibility for families.”

An at-risk patient population

Kids are struggling, Boger explains, with one in three children meeting the criteria for an anxiety disorder by the time they turn 18, and yet only one in five will actually get the care they need.

“Even fewer kids get access to evidence-based treatment backed by research,” she says. “Cognitive behavioral therapy or CBT is unfortunately not accessible for many families. It’s often self-pay, and providers have long wait lists.”

The insurance piece is a huge barrier, Boger notes.

“We need to make it more feasible for providers to take insurance,” she says. “Most CBT providers I know are self-pay because they can’t afford to take insurance because of how reimbursement works.”

Another barrier to success is the mental and emotional toll of taking care of a patient with mental health needs.

“If a kid is struggling, typically the system around them is struggling,” Boger says. “It’s why we work with the family, the school, the pediatrician, so they’re all involved in care and the young person is getting ‘surround sound’ messaging from everyone. It’s harder for kids to make progress if the system around them isn’t aligned on treatment planning.”

Boger says anxiety can be considered a “gateway disorder.”

“If left untreated, or ineffectively treated, it can lead to a whole host of other issues: depression, suicidality, substance abuse, and from there the problem is growing and growing and becoming more costly,” she says. “From the family perspective, it can cause a strain on their system as family members take leaves of absence from work or experience their own mental health challenges due to that strain.”

How the care model works

The program has three phases, starting with more touchpoints per week and reducing intensity across the phases. The three-person care team follows the patient and family through the whole care journey which is purposefully time-bound (ranging from four to 12 months). “We want to activate the environment, to teach kids and families and schools new ways to respond to anxiety and OCD,” Boger explains. “We know we’re successful when they don’t need us anymore, when they know how to effectively respond when they hit speed bumps.”

Teaching these skills to both young people and their parents is a core part of the program, Boger says, because parenting instincts often run counter to what’s actually effective in managing anxiety and OCD. “Our instincts as parents are to protect our kids. We don’t want them to be in pain, or in distress, or feel afraid,” she says. “What’s challenging with a kid with anxiety or OCD is the more you do to protect them from feeling the anxiety, it provides relief in the short term but grows that anxiety in the long term.” Through this cycle of accommodation, the young person learns that they can’t handle the situation and they are robbed of the opportunity to manage it.

“We have to learn to let them know it’s okay to feel afraid and encourage them to face their fears and do hard things,” Boger says. “We give them opportunities to practice, and give them support as they go, so they and their parents feel empowered and equipped to navigate life.”

This is why so much of the program directly interacts with families and other support systems, she says.

“We often say the road of life is bumpy, and you, as a parent, have a choice: you can prepare your child for the road, or you can prepare the road for your child. You can either smooth out all the bumps or you can prepare the child to navigate the bumps on their own,” says Boger.

Beyond the appointment

One of the strengths of the program is that it deviates from the classic once a week, 50-minute model. “InStride care is accessible between sessions,” says Boger. “Patients can reach out in real time, and coaches reach out proactively throughout the week. It’s like having an adult in their back pocket.”

Additionally, the virtual model makes care more accessible to families. “When we were in-person, we had families driving long distances for our care. They were desperate,” says Boger. “And it was getting in the way of school and work. Now, we can have kids log in during a study hall, a break in their school day, or after school, and parents can join their parent group sessions while preparing dinner. It lets us families build the treatment around their life.”

From here, InStride Health hopes to continue to make sure their evidence-based model is available to more and more patients while maintaining the same level of quality of care. “Quality is our north star and what drives us,” says Boger.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.