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Cognitive and Behavioral Practice 28 (2021) 350–363

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Development and Implementation of a Transdiagnostic,

Stepped-Care Approach to Treating Emotional Disorders in
Children via Telehealth
Sarah M. Kennedy, University of Colorado School of Medicine
Hillary Lanier, Baylor College of Medicine
Alison Salloum, University of South Florida
Jill Ehrenreich-May, University of Miami
Eric A. Storch, Baylor College of Medicine

Stepped-care interventions may increase the accessibility of evidence-based treatments but remain relatively underexplored
in the child mental health literature. Further, while the feasibility and efficacy of stepped-care interventions have been
examined for specific diagnoses or classes or disorders, transdiagnostic stepped-care interventions have not yet been devel-
oped. We discuss the development and initial implementation of a transdiagnostic approach to emotional disorders using
the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al.,
2018). A case series is presented to illustrate the delivery of UP-C stepped care (UPC-SC) via telehealth, using a collabo-
rative decision-making process to inform step-up/step-down decisions. Lessons learned are discussed to guide refinements of
UPC-SC and inform a larger trial.

A n “emotional disorder” is an overarching term

that describes a group of disorders defined by
their shared underlying mechanisms: elevated negative
emotional disorders that can be widely and flexibly
disseminated.
Over the past several decades, efficacious treatments
affect, negative reactivity to intense emotions, and have been developed to address impairing psychiatric
efforts to avoid or dampen those emotional experi- diagnoses (e.g., panic disorder, obsessive-compulsive
ences or the contextual factors that elicit them disorder [OCD]) and diagnostic classes (e.g., anxiety
(Bullis et al., 2019). This definition encompasses a disorders, depressive disorders) in youth. However,
broad range of psychiatric disorders, including anxiety, current evidence-based treatments for youth may lack
depressive, obsessive-compulsive spectrum, and stress- the flexibility to adequately address comorbidity and
and trauma-related concerns. In addition to being incorporate the multitude of sometimes frequently
highly prevalent among children and adolescents shifting problem areas experienced by youth with emo-
(e.g., Beesdo et al., 2009; Costello et al., 2006; tional disorders (e.g., dysregulation of anger, frequent
Lewinsohn et al., 1998), emotional disorders in youth experience of guilt and shame, personality disorder
are associated with significant functional impairment features, disordered eating). Further, some youth
across domains (e.g., Jaycox et al., 2009; Scheier & may require the full 12–16 sessions typical of
Botvin, 1997) and have a high economic burden evidence-based interventions and may subsequently
(Farrell & Barrett, 2007). The persistence of many benefit from even more sessions, as evidenced by non-
emotional disorders into adulthood when left inade- response rates of 40–50% in previous anxiety and
quately treated, and the high demand for services, depression treatment trials (e.g., Kendall et al., 2008;
underscore the need for efficacious interventions for Treatment for Adolescents with Depression Study
Team, 2004; Walkup et al., 2008). However, other
youth appear to exhibit trajectories of early or rapid
response to treatment (e.g., Skriner et al., 2019) and
Keywords: child; transdiagnostic; treatment; stepped care; may require fewer overall sessions or an early tapering
telehealth of treatment. Developing flexible, adaptive treatment
1077-7229/20/Ó 2021 Association for Behavioral and Cognitive approaches able to address the varying diagnostic pro-
Therapies. Published by Elsevier Ltd. All rights reserved.
 Transdiagnostic Stepped-Care Approach via Telehealth 351

files and trajectories of change in youth is essential to indicate that therapists spend significantly less time pro-
furthering dissemination efforts. viding stepped-care interventions than standard care or
The high prevalence of emotional disorders in standard-format evidence-based treatments (Rapee
youth, combined with the limited dissemination of et al., 2017), and the former are associated with signifi-
evidence-based treatments into practice settings and cant cost savings (Salloum et al., 2016).
the inadequacy of the mental health infrastructure in The studies reviewed above take a disorder-specific
many areas to meet current need (Asnaani et al., or domain-specific treatment approach to the delivery
2018), demand that lower-resource, first-line interven- of stepped-care interventions in youth, focusing on
tions be developed. Stepped-care intervention treating youth with a single diagnosis or class of disor-
approaches in youth with emotional disorders may der. The Unified Protocols for Transdiagnostic Treat-
facilitate the dissemination of evidence-based interven- ment of Emotional Disorders in Children (UP-C;
tions into practice settings and help meet the high Ehrenreich-May et al., 2018), which targets core dys-
need for mental health services in youth. Stepped care functions underlying emotional disorders, may be an
is a mode of intervention delivery that begins by provid- ideal vehicle for providing stepped-care interventions
ing an initial, relatively brief “dose” of an intervention for children due to its flexible format and transdiag-
(i.e., a first “step”) targeting chief symptoms or under- nostic approach. The UP-C is a developmentally tai-
lying mechanisms thought to maintain the disorder or lored adaptation of the Unified Protocol for
identified area of concern. Treatment response is Transdiagnostic Treatment of Emotional Disorders
assessed after this initial step using a priori criteria, (Barlow et al., 2017) that addresses core dysfunctions
and youth achieving responder status typically “step underlying emotional disorders in children, including
down” to a less intensive version of the intervention high negative affect, aversive reactions to intense emo-
or treatment discontinuation, while nonresponders tions, and use of problematic emotion regulation
“step up” to receive additional treatment and/or a strategies that exacerbate negative emotions in the
more intensive treatment format. long term (e.g., suppression, avoidance). The UP-C
Research to date on stepped care for youth anxiety, contains both child-directed materials targeting these
depression, and posttraumatic stress disorder has sup- core dysfunctions, as well as parent-directed interven-
ported the acceptability and feasibility of this approach tions targeting “emotional parenting behaviors” impli-
and has begun to demonstrate its advantages over the cated in emotional disorders in youth, including
standard approach to providing evidence-based inter- criticism, inconsistency, overprotection, and emotional
ventions. Pilot studies on stepped-care approaches to modeling (Ehrenreich-May et al., 2018). The treatment
delivering trauma-focused cognitive-behavioral therapy was originally conceived as a 15-session group interven-
(CBT) for children (Salloum et al., 2014, 2016), and tion, including separate individual and parent groups
interpersonal therapy for adolescents (IPT-A) for that are concurrently run, but can also be delivered,
depression (Mufson et al., 2018), for example, have in a 15-session individual format. The feasibility,
found evidence of high levels of patient and/or parent acceptability, and efficacy of the full-package UP-C in
satisfaction with treatment as well as patient and thera- treating children with anxiety and depressive disorders
pist adherence to treatment. Additionally, between 15 has been supported across open and randomized trial
and 43% of youth in studies reviewed achieved diagnos- designs (e.g., Ehrenreich-May, 2012; Kennedy et al.,
tic remission after Step 1 of a stepped-care intervention 2019), and pilot data have provided support for the fea-
(Mufson et al., 2018; Pettit et al., 2017; Salloum et al., sibility, acceptability, and initial efficacy of use of the
2016), and one study of a stepped-care, CBT-based UP-C in children with elevated irritability and disrup-
approach to treating child anxiety found a 72% remis- tive behaviors (Hawks et al., 2020).
sion rate at 12-month follow-up for youth who had com- Transdiagnostic interventions, such as the UP-C,
pleted Step 1 only, which was not significantly different may have several advantages over other evidence-
from the remission rates for youth who had completed based treatments when implemented in a stepped-
more intensive interventions (Rapee et al., 2017). It is care format. First, rather than clinicians having to
also important to note that Step 1 in several of these tri- select and match patients to separate interventions
als was a low-intensity and low-resource intervention, for comorbid diagnoses and determine how to
such as bibliotherapy with therapist support (Rapee sequence such interventions, the UP-C allows clinicians
et al., 2017) or attention-bias modification training to target multiple emotional disorders using a singular
(Pettit et al., 2017). Taken together, these findings sug- set of core interventions. This feature of the UP-C may
gest that a significant proportion of youth may require reduce overall treatment duration and allow for differ-
only a low-dose and low-intensity intervention to achieve ent symptom sets and problem areas to be addressed in
optimal benefit, and stepped-care approaches may free a single, brief intervention format or an initial “step.”
up resources and therapist time for youth who do Additionally, the UP-C contains separate intervention
require more intensive interventions. Indeed, results components designed to target risk and maintenance
352 Kennedy et al.

factors underlying emotional disorders (e.g., anxiety each step is crucial. We drew on several sources of
sensitivity, cognitive inflexibility, behavioral avoid- information to inform these decisions, including the
ance). Although participants in the current pilot trial designs of previously conducted stepped-care trials
all received the same initial step, the structure of the for youth emotional disorders, findings on trajectories
UP-C provides future opportunities to personalize of change from previous treatment trials, and the
stepped-care interventions by matching initial and sub- research team’s prior clinical experiences in imple-
sequent steps to specific risk and maintaining factors. menting the UP-C. Crucially, the first step needed to
The objective of the current treatment development be long enough for a substantial proportion of youth
paper is to provide an overview of the development and to demonstrate meaningful improvement, and the
initial implementation of a stepped-care model for entire length of the UPC-SC needed not to exceed
delivery of the UP-C (UPC-SC), provided via telehealth, the length of the full treatment protocol.
to inform future trials of stepped-care delivery of trans- A review of previous stepped-care intervention trials
diagnostic interventions for children. Telehealth is for youth revealed that most trials included either two
becoming an increasingly appealing solution for cir- or three steps, and the number of sessions included in
cumventing multiple barriers that restrict youth access Step 1 ranged from 4 to 14 “sessions” facilitated by
to mental health services, including geographic, trans- either a parent or clinicians, with a mean number of
portation, and financial issues (Hilty et al., 2013). At sessions of 8.60 (Mufson et al., 2018; Pettit et al.,
the same time, widespread accessibility of high-speed 2017; Rapee et al., 2017; Salloum et al., 2014; van der
Internet services has made telehealth an increasingly Leeden et al., 2011). Although this range is quite large,
plausible option for fulfilling unmet mental health many of the Step 1 interventions in the trials reviewed
care needs. Although still an emerging intervention contained at least some sessions composed of low-
platform, studies of telehealth interventions for mental intensity interventions, such as brief parent and/or
health conditions have found evidence of comparable adolescent phone consultations, parent–child review
efficacy to in-person delivery formats, as well as high cli- and practice of therapeutic content at home (Rapee
ent and clinician satisfaction (Backhaus et al., 2012; et al., 2017; Salloum et al., 2014), or 15-minute atten-
Perle & Nierenberg, 2013). Additionally, several pilot tion bias modification training sessions (Pettit et al.,
and case studies have supported the feasibility and ini- 2017). An examination of the youth treatment litera-
tial efficacy of telehealth delivery of evidence-based ture on trajectories of change for children and adoles-
interventions for emotional disorders in children, cents indicated that meaningful improvement in both
including posttraumatic stress disorder (Stewart et al., child- and parent-reported symptoms can be observed
2017) and anxiety (Cooper-Vince et al., 2016; Storch during the first six sessions of cognitive-behavioral
et al., 2011). treatment for anxiety (Chu et al., 2013; Skriner et al.,
In the following sections, we describe the develop- 2019). Additionally, several studies of CBT for youth
ment of a model for delivering the UP-C in a emotional disorders have found that youth achieving
stepped-care intervention format, illustrating its early responder status (defined as between Weeks 2
strengths and challenges using several case examples and 8 of treatment) are highly likely to maintain
from an ongoing pilot study that included families that responder status at follow-up and less likely to show evi-
endured and/or were emotionally impacted by a hurri- dence of symptom recurrence over time (e.g., Pettit
cane in the Southern United States. Our primary aims et al., 2017; Renaud et al., 1998; Wamser-Nanney
are to (a) describe considerations in the development et al., 2016).
of UPC-SC; (b) describe the collaborative decision- Consistent with many previous stepped-care inter-
making process used for arriving at a decision about ventions reviewed above, we designed the UPC-SC to
whether the client should step up or down after an ini- comprise two steps, including six sessions each, with
tial dose of treatment; (c) illustrate the delivery of the total number of sessions across all steps totaling
UPC-SC via three brief case examples, highlighting 12, which is three sessions less than the full UP-C treat-
the use of our collaborative decision-making process; ment administered in previous open and randomized
and (d) identify opportunities and challenges in the trials (Bilek & Ehrenreich-May, 2012; Kennedy et al.,
delivery of a transdiagnostic approach to stepped care 2019). In contrast to several other stepped-care models
in children. using primarily lower-resource and lower-intensity
interventions in Step 1, four of our six Step 1 sessions
Development of UP-C Stepped Care were standard-length, 50-minute clinician-facilitated
sessions, although we did include two shorter parent
Number and Length of Steps phone support sessions in Step 1 (see description of
Step 1 below for further information). All treatment
When developing a stepped-care approach to inter- components across the two steps appear in the UP-C
vention for youth with emotional disorders, considera- Therapist Guide and Workbooks (Ehrenreich-May
tion of the appropriate number of steps and length of
 Transdiagnostic Stepped-Care Approach via Telehealth 353

et al., 2018) and were components of the full UP-C for some potential benefits of parent-led approaches
intervention delivered in previous open and random- over child-focused approaches (e.g., greater reductions
ized trials (Bilek & Ehrenreich-May, 2012; Kennedy in accommodation; Lebowitz et al., 2020). We viewed
et al., 2019). Table 1 includes a summary of session parent involvement in treatment as especially crucial,
content in each of the two steps, the details of which given the telehealth delivery format of this interven-
are explicated in subsequent sections of this paper. tion. Practical considerations such as the need to cre-
UP-C workbook materials were e-mailed to the parent ate a private and suitable therapy space inside the
(s) of the participant prior to beginning UPC-SC. home and the need for technological support and
troubleshooting necessitated a substantial parent pres-
Step 1 ence. Additionally, parents were regularly recruited to
assist with exposure and opposite action activities both
Step 1 comprised four 50-minute joint parent–child within and between sessions. UP-C parent session mate-
sessions conducted using the Vidyo telehealth plat- rial, which includes psychoeducation and strategies
form, including one session reviewing transdiagnostic, related to “emotional parenting behaviors” (e.g., over-
emotion-focused psychoeducation and three sessions protection, inconsistency, criticism, modeling of avoid-
focused on exposure and acting opposite to behavioral ance) and “opposite parenting behaviors” (e.g.,
action tendencies associated with strong emotions (i.e., healthy independence granting, consistency, strategic
emotional behaviors). Additionally, two 30- to 40- attention and empathy, healthy emotional modeling),
minute parent-only phone- or tele-support sessions was introduced as needed during parent phone sup-
(depending on parent preference) were conducted as port sessions in addition to assisting parents with plan-
part of Step 1. We chose to focus Step 1 on teaching ning and supporting exposure. An additional seventh
children to initiate different or “opposite” actions to “flex session” was provided as an option for clients step-
emotionally driven behaviors for several reasons. First, ping down after Step 1, during which the clinician was
acting opposite to strong emotions is a widely applica- able to focus either on the practice of previously intro-
ble technique that is pervasive across many disorder- duced content or introduction of new content from
or domain-specific interventions for youth. Techniques any session in standard UP-C.
for acting opposite to intense emotions include expo-
sure for anxiety, exposure and response prevention
for OCD, behavioral activation for depression, and Collaborative Decision-Making Approach
frustration tolerance exposures for anger and irritabil- to Stepping Up or Down
ity (e.g., Hawks et al., 2020; Stringaris et al., 2018).
Additionally, evidence from recent pilot trials indicates Consistent with typical clinical practice, a collabora-
that interventions focused on acting opposite to emo- tive decision-making approach involving the clinician,
tionally driven behaviors, such as exposure, are accept- client, and parent informed the decision regarding
able and efficacious when used early in treatment or as whether the child and parent would step up or down
stand-alone interventions (Whiteside et al., 2015) and following Step 1. Collaborative decision making is a
may even be more strongly related to treatment form of patient-centered care that features the patient
response than cognitive interventions (Ale et al., as a key stakeholder in decisions surrounding treat-
2015). Given evidence in support of exposure and ment selection and planning. Research on collabora-
other behavioral interventions as a first-line interven- tive decision making in medicine has enumerated
tion strategy for youth emotional disorders, the first many benefits, including more accurate perception of
step in the current stepped-care version of the UP-C risks and benefits of treatment options, increased
focused on teaching youth to act opposite to intense knowledge, lower decisional conflict, and higher rates
emotions. of treatment completion (Barry & Edgman-Levitan,
Similar to other stepped-care interventions reviewed 2012; Lindhiem et al., 2014). Collaborative decision
above, we also included two parent-only phone support making has been studied much less extensively in the
sessions in Step 1 as a lower-intensity adjunctive inter- mental health arena and particularly with regard to
vention. Although previous literature has found com- child mental health, where the participation of multi-
parable outcomes between child-only and child-and- ple stakeholders in treatment-related decisions (e.g.,
parent treatment for emotional disorders in youth youth, parents) and often low agreement among youth
(Reynolds et al., 2012), the variability of and lack of and parents about mental health decisions may make a
detail regarding parent incorporation in treatment in collaborative decision-making approach more chal-
many previously published studies makes it difficult lenging (Langer & Jensen-Doss, 2018). Nevertheless,
to draw conclusions about the potential for parents parent report of perceived involvement in decision
to enhance outcomes. Recent studies have provided making regarding their child’s mental health care has
support for the noninferiority of parent-led been associated with increased satisfaction and lower
approaches to youth emotional disorders and even impairment (Butler et al., 2015). Additionally, one
354 Kennedy et al.

Table 1
UP-C Stepped-Care Intervention Components
Child-directed component Parent-directed component
Step 1
Session 1 UP-C Standard Sessions 1 and 2 UP-C Standard Session 2
How to deal with strong emotions Double before, during, and after
Consider your thoughts, feelings, and behaviors
Session 2 UP-C Standard Sessions 2 and 10 UP-C Standard Session 10+
Cycle of emotional behaviors My Emotion Ladder
Introduction to exposure Exposure planning
My Emotion Ladder
Session 3 UP-C Standard Session 3 UP-C Standard Session 2
Acting opposite to strong emotions Introduction to emotional and opposite parenting
Emotional behavior science experiments behaviors
My Activities List for acting opposite Discussion of specific opposite parenting
behaviors as needed
Session 4 Not applicable Phone support session
Exposure planning
Discussion of specific opposite parenting
behaviors as needed
Session 5 UP-C Standard Sessions 4, 8, and 10+ UP-C Standard Session 10+
Body clues and body scanning Exposure planning and support
Present-moment awareness
Exposure and acting opposite experiments
Session 6 Not applicable Phone support session
Step up/down decision making
Discharge planning
Exposure planning
Flex Content variable, but typically UP-C Standard Content variable
session Sessions 5 and 6 (cognitive flexibility, detective
thinking)
Step 2
Session 1 Variable, depending on needs Variable, depending on needs
Session 2
Session 3
Session 4 Not applicable Phone support session
Session 5 Variable, depending on needs Variable, depending on needs
Session 6 Not applicable Phone support session
Note. During Session 6, a collaborative decision-making process, guided by “top problem” ratings and Step Up/Step Down Questionnaire
feedback, was used to arrive at a decision regarding whether to step up or step down. Clients agreeing to step down received an additional
“flex session,” while clients stepping up proceeded to Session 1 of Step 2.

study found that adolescents and young adults who Top problem ratings from the youth and parent
participated in a hybrid online and in-person collabo- (Weisz et al., 2011), and a Step Up/Step Down Ques-
rative decision-making intervention reported lower tionnaire developed specifically for the purpose of
conflict about which treatment option to choose, were piloting this novel stepped-care model, were used to
more likely to choose interventions concordant with inform a collaborative decision-making approach to
evidence-based practices, and reported high satisfac- deciding whether to step up or down. Top problems,
tion with the decision-making process (Simmons consisting of three problems identified by the parent
et al., 2017). Given compelling evidence regarding and child as the most important treatment targets
the benefits of shared decision making, and similar and rated each week on a 0 (not a problem) to 8 (huge
to procedures used by Rapee et al. (2017), we incorpo- problem) scale, are idiographic measures of treatment
rated this approach in the current study at predeter- progress that have demonstrated good convergent
mined decision points to make collaborative and divergent validity and are sensitive to treatment
decisions with clients and families regarding whether change (Weisz et al., 2011). The clinician administer-
to step up or step down. ing the UPC-SC provided information about changes
 Transdiagnostic Stepped-Care Approach via Telehealth 355

in top problem ratings at Session 6. Additionally, the the family was the ultimate decision maker regarding
clinician asked the parent and child to complete the the next step of treatment in cases of discrepancy.
Step Up/Step Down Client Questionnaire (sent to
the family via e-mail after Session 5) and discussed Step 2
results of this questionnaire with the family at Session Similar to Step 1, Step 2 of the intervention com-
6. The Step Up/Step Down Questionnaire is a 12- prised four 50-minute sessions with the child and par-
item measure that assesses readiness to step down fol- ent together and two 30- to 40-minute phone support
lowing Step 1 of the UPC-SC. The parent completed sessions with the parent alone. In contrast to Step 1,
the “client” version of the questionnaire with the which comprised a standardized sequence of interven-
child’s input, and the clinician also completed a “clin- tion components, the clinician was free to select from a
ician” version of the questionnaire. Items are rated on menu of clinically appropriate parent- or child-focused
a 5-point Likert-type scale (0 = does not apply, 1 = not at interventions from the UP-C when delivering Step 2.
all true, 2 = somewhat true, 3 = mostly true, 4 = true to a great We decided to incorporate a high degree of flexibility
extent). Instructions in the client version of the ques- in Step 2 to accommodate the various presenting con-
tionnaire prompt the caregiver to answer each ques- cerns capable of being addressed with a transdiagnostic
tion from “your and your child’s perspective.” Groups treatment such as the UP-C, as well as to gather addi-
of items assess caregiver and child perception of tional data on the most commonly employed Step 2
improvement (e.g., “My child’s primary presenting interventions to inform a UPC-SC clinical trial.
problems have improved because of treatment”),
acquisition and skills use (e.g., “My child has increased
Clinician Training and Consultation
their ability to recognize and/or appropriately express
their emotions"), satisfaction with the content of each
Treatment was provided by a licensed clinical social
session, and readiness to terminate treatment (e.g.,
worker, with approximately 3 years of postlicensure
“My child feels that he or she no longer needs ther-
experience and prior clinical experience with deliver-
apy”). The clinician version of the questionnaire was
ing evidence-based treatments, who was employed at
completed after Session 5 and contains similarly
an academic health sciences center in the southwest-
worded items, but the clinician is asked to “answer
ern region of the United States. The clinician partici-
the following questions about your client from your per-
pated in a 16-hour clinical training conducted JE-M
spective.” Although items can be summed to yield a total
(a certified UP-C trainer), as well as weekly, 1-hour con-
score, the measure was examined qualitatively in this
study when making decisions about whether to step
up or down.
To mirror real-world practice and preference for
collaborative decision making regarding youth treat-
ment, the clinician used data from top problem ratings
and the Step Up/Step Down Questionnaires to advise
the parent and child whether or not to continue with
the next step of treatment. Although we did not strictly
adhere to standardized algorithms to guide this pro-
cess, the following general guidelines (illustrated in
Figure 1) were used as benchmarks for readiness to
step down: (a) the majority of top problem ratings
< 4; (b) the majority of items related to perceptions
of youth improvement and skills acquisition on the
Step Up/Step Down Questionnaire being rated as
“Mostly true” or “To a great extent true”; and (c)
endorsement of readiness to terminate therapy as
“Mostly true” or “To a great extent true.” In cases
where patterns of responding were discrepant, the clin-
ician attempted to resolve this discrepancy by assessing
the reasons for it and by using interventions to either
increase the family’s engagement with treatment (if
the clinician recommended stepping up but the family
preferred to step down) or increase readiness for ter-
mination (if the clinician recommended stepping
down but the family preferred to step up). However, Figure 1. Flowchart illustrating step up/step down collabo-
rative decision-making process.
356 Kennedy et al.

sultation calls for the duration of the project led by the Strengths and Difficulties Questionnaire, Parent Version
same individual and SMK (also a certified UP-C trai- (SDQ-P)
ner). Consultation calls focused on monitoring adher- The SDQ-P (Goodman, 2001) is a 25-item, parent-
ence, providing guidance on the flexible application of report measure of emotional and behavioral symptoms
the intervention, and troubleshooting issues that arose and social functioning in children and adolescents.
in implementation. Respondents are asked to rate how true each item is
of their child on a 3-point scale (0 = not true, 1 = some-
Participants what true, 2 = certainly true). Four of the five subscales
are summed to yield a Total Problems scale (used in
The UPC-SC was piloted with three children and this study). The SDQ has been demonstrated to have
their parent(s), case examples of which are provided strong psychometric properties (Goodman, 2001).
in the following sections. Participant 1, “Nate,” was a
9-year-old White male with a primary diagnosis of gen- Pediatric Quality of Life Enjoyment and Satisfaction
eralized anxiety disorder. Participant 2, “Regan,” was a Questionnaire, Parent Version (PQ-LES-Q-P)
7-year-old White female with a primary diagnosis of dis- The PQ-LES-Q-P (Endicott et al., 2006) is a 15-item,
ruptive mood dysregulation disorder and a secondary parent-report measure for children ages 6–17 assessing
diagnosis of attention-deficit/hyperactivity disorder. quality of life across different domains, including
Participant 3, “Will,” was a 10-year-old Black male with health, school, home, peer relationships, and self-
a primary diagnosis of adjustment disorder. esteem. We adapted this measure from the child-
report PQ-LES-Q for the purpose of this and similar
Measures studies. Respondents are asked to rate quality of life
over the past week using a 5-point scale (1 = very poor,
In addition to the Step Up/Step Down Client and 2 = poor, 3 = fair, 4 = good, 5 = very good). The first 14
Clinician Questionnaires and top problem ratings (dis- items are summed to yield a total raw score, with higher
cussed previously), the parent and/or child also com- scores indicating greater enjoyment and satisfaction
pleted the following measures at baseline and with life. The psychometric properties of the child ver-
posttreatment: sion of the measure have been established in youth
with major depressive disorder and OCD (Endicott
Spence Children’s Anxiety Scale, Child and Parent Versions et al., 2006; Wellen et al., 2017).
(SCAS-C/P)
The SCAS-C and SCAS-P (Nauta et al., 2004; Spence, Case Examples
1997, 1998) are 38-item child- and parent-report mea- IRB approval was obtained prior to beginning study
sures, respectively, of anxiety disorder symptoms in procedures, which were followed in accordance with
children. The measure contains six subscales assessing the ethical standards of the IRB and the Helsinki Dec-
symptoms of the fourth edition Diagnostic and Statistical laration of 1975. All participants/parents provided
Manual of Mental Disorders (DSM-IV) anxiety disorders, informed consent/assent to study procedures, and
and respondents indicate how often each statement is pseudonyms are used in the case examples below to
true of them/their child on a 4-point scale from 0 protect confidentiality of participants.
(never) to 3 (always). Items are summed to yield a total
anxiety score and converted to t scores, with a t score Case 1: Step Down After Step 1, High
 60 indicating elevated anxiety (Dadds et al., 1999). Clinician and Client Agreement About Step
Numerous studies have supported the psychometric Down
properties of the scales (Spence, 1997, 1998).
“Nate” presented to treatment with daily worries
Short Mood and Feelings Questionnaire, Child and Parent about many topics, including family finances, school
Versions (SMFQ-C/P) performance, and pleasing others. Nate’s family was
The SMFQ-C and SMFQ-P (Messer, Angold, impacted by a major hurricane 18 months prior to ini-
Costello, & Loeber, 1995) are 13-item child- and tiating treatment, after which Nate experienced
parent-report measures, respectively, of depression increased worries, particularly around separation and
symptoms in children. Respondents are asked to rate sleeping alone. At baseline, Nate was sleeping with
their agreement with each statement on a 3-point scale his brother on a nightly basis and was engaging in
(0 = not true, 1 = sometimes, 2 = true). Items are summed excessive checking on whereabouts of family members
to yield a total score, and prior research has indicated and reassurance seeking regarding safety. Top prob-
that a total score of 8 or more on the SMFQ-C has a lems identified by Nate and his mother included (a)
sensitivity of 60% and a specificity of 85% for major feeling anxious when separated from his mother (Nate
depressive disorder (Messer et al., 1995). and mother rating = 7/8), (b) high self-criticism (Nate
 Transdiagnostic Stepped-Care Approach via Telehealth 357

and mother rating = 6/8), and (c) school and test anx- an introduction of thinking traps and detective think-
iety (Nate and mother rating = 6/8). ing to address the patient’s cognitive rigidity and exces-
During Step 1, exposures primarily focused on sive reassurance seeking, as well as a celebration of
addressing separation anxiety, with Nate working up progress and relapse prevention.
from reducing the frequency of phone calls to his Overall, Nate’s anxiety scores decreased from base-
mother to spending increasingly longer periods away line (BL) to posttreatment (Post) based on self-report
from his mother to being separated from his mother (BL SCAS-C T score = 62, Post SCAS-C T score = 47)
without knowing her whereabouts. Nate also com- and parent report (BL SCAS-P T score = 65, Post
pleted exposures involving successive steps toward SCAS-P T score = 58). Scores on the SMFQ and SDQ
sleeping alone in his bed. Session 4 entailed a phone were low and remained low throughout treatment.
support session with Nate’s mother that focused on dis- Self-reported quality of life also increased slightly dur-
cussing progress with exposures, troubleshooting, and ing treatment (BL PQ-LES-Q raw score = 62, Post PQ-
identifying subsequent exposures to complete over LES-Q raw score = 69). Nate’s case illustrates a rela-
the coming week. In Session 5, Nate was provided with tively straightforward example of the utility of a
additional intervention around body clues, was intro- stepped-care model for streamlining treatment when
duced to the idea of present-moment awareness, and progress occurs rapidly and all reporters are in agree-
learned and practiced body scanning. The clinician ment regarding treatment gains.
worked with Nate and his mother to update Nate’s
“My Emotion Ladder” and to plan further exposures
for the coming week. The sixth and final session of Case 2: Step Up After Step 1, High Clinician
Step 1 was a phone support session with Nate’s mother, and Client Agreement About Step Up
during which the clinician obtained an update about
Nate’s progress with exposures and assisted Nate’s “Regan” reportedly began experiencing opposi-
mother with planning additional exposures. Nate had tional behavior and emotion dysregulation at the age
also been engaging in some excessive reassurance seek- of 3, had previously received a diagnosis of opposi-
ing, so the clinician worked with Nate’s mother to pro- tional defiant disorder, and had undergone past treat-
vide psychoeducation about reassurance seeking as a ment with little reported improvement. At baseline,
form of overcontrol/overprotection and assisted Nate’s Regan was experiencing two to three episodes per
mother with reducing this behavior. day, lasting up to 60 minutes each, during which she
During the Session 6 parent support phone call, the would become oppositional and dysregulated. Triggers
clinician engaged Nate’s mother in a collaborative included being given a command, being told “no,” or
decision-making process to inform the decision of having her behavior corrected. Top problems identi-
whether to step up or step down. The severity of Nate’s fied by Regan and her mother included the following:
top problems had all decreased significantly, as illus- (a) out-of-control meltdowns whenever Regan does
trated by the following ratings: (a) feeling anxious something wrong or is corrected (Regan and mother
when separated from mother (Nate and mother rating rating = 7/8), (b) negative self-talk during meltdowns
= 0/8, 88% decrease from baseline), (b) high self- (Regan rating = 8/8, mother rating = 7/8), and (c)
criticism (Nate rating = 0/8, 100% decrease from base- talking back when given a command (Regan and
line; mother rating = 1/8, 83% decrease from base- mother rating = 8/8).
line), and (c) school and test anxiety (Nate rating = During the first session of Step 1, Regan was intro-
1/8, 83% decrease from baseline; mother rating = duced to the three parts of an emotion and the “cycle
2/8, 67% decrease from baseline). One hundred per- of angry behaviors.” Regan demonstrated good insight
cent of the items from the Step Up/Step Down Clini- into the unhelpfulness of some of her emotional
cian Questionnaire assessing clinician perception of behaviors, including yelling, crying, and noncompli-
patient improvement were rated as being “True to a ance. However, she expressed difficulty controlling
great extent,” and an examination of the Step Up/Step these outbursts, stating, “I try to be good, but my body
Down Client Questionnaire indicated that most items disobeys my brain.” In Session 2, the clinician contin-
were rated by the parent as “Mostly true” or “True to ued to assist Regan with breaking down her emotions
a great extent.” Nate was also sleeping in his room and introduced her and her mother to the concepts
alone every night and spending extended periods of of exposure and “riding the wave.” Steps on Regan’s
time away from his parents. Based on top problem rat- stepladder included items related to being told “no,”
ings, examination of Step Up/Step Down Question- being corrected, and not getting her way. In Session
naires, and qualitative feedback provided by the 3, Regan was introduced to the concept of acting oppo-
family, the recommendation to step down was made site to emotions and completed a “My Activities List” to
and accepted by the family. The clinician and family generate options for acting opposite to frustration.
agreed to do a final seventh “flex session” that entailed Additionally, due to Regan’s significant oppositional
behaviors and emotional dysregulation, her mother
358 Kennedy et al.

was introduced to the emotional parenting behavior of During the first three sessions of Step 2, the clini-
inconsistency and the opposite parenting behavior of cian chose to continue to focus on exposure and oppo-
consistent reinforcement and consequences, as well site action, including both frustration tolerance
as the emotional parenting behavior of criticism and exposures and exposure and response prevention to
its opposite parenting behavior of strategic attention. address compulsive behaviors. The clinician also con-
The clinician worked with the family to implement a tinued to work with the client’s mother on differential
token system to reward positive behaviors and expo- attention and consistent use of consequences, includ-
sure completion and provide consequences for identi- ing implementation of a response cost system whereby
fied behaviors (e.g., talking back). the client would lose a token for “talking back.” During
Regan and her mother continued to complete steps the fourth session of Step 2, the therapist worked with
on Regan’s “My Emotion Ladder” for between-session the client and her mother to create a “meltdown emer-
practice, and in Session 4, the clinician continued to gency plan” for Regan to implement when she first
work with Regan on acting opposite to frustration began to notice body clues for frustration in order to
and completing additional steps on her ladder. During prevent meltdowns. During the fifth session of Step 2,
these exposures, the clinician became aware of obses- a parent phone support session was held. The clinician
sions and compulsions underlying some of Regan’s worked with Regan’s parents to develop a “parent melt-
meltdowns—for example, Regan often became dysreg- down plan” incorporating opposite parenting behav-
ulated or oppositional when prevented from putting a iors covered thus far in the UPC-SC with the family
toy back in the “right” spot or arranging things in a par- (e.g., consistently prompting Regan to use her melt-
ticular way. Exposure and response prevention targets down plan, rewarding even partial use of plan, ignor-
were therefore incorporated into Regan’s “My Emotion ing minor misbehaviors, being consistent in
Ladder.” Session 5 was a parent phone support session, responses across parents). The clinician also reminded
during which the clinician reviewed Regan’s progress parents that the next session would be the final session
with exposures and helped troubleshoot her mother’s of Step 2. The clinician recommended that Regan step
use of opposite parenting behaviors. down after the next session, due to parent report that
During the Session 6 parent support phone call, the Regan’s meltdowns had decreased in both frequency
clinician engaged Regan’s mother in a collaborative and intensity and were now lasting only about 10 min-
decision-making process to inform the decision of utes. However, Regan’s parents were initially hesitant
whether to step up or step down. The severity of to terminate treatment, explaining their perception
Regan’s top problems had all decreased (a) out-of- that Regan’s behaviors often improved directly follow-
control meltdowns when corrected (Regan and mother ing her weekly session with the clinician. The clinician
rating = 3/8, 57% decrease from baseline), (b) nega- attempted to transfer control back to Regan’s parents
tive self-talk during meltdowns (Regan rating = 2/8, and build self-efficacy, and it was agreed that Regan
75% decrease from baseline; mother rating = 3/8, would step down following the next session.
5% decrease from baseline), and (c) talking back when During the final session of Step 2, the clinician
given a command (Regan and mother rating = 4/8, reviewed both the parent and client meltdown plans
50% decrease from baseline). On the Step Up/Step and had an opportunity to coach both Regan and
Down Clinician Questionnaire, 55% of items assessing her mother in implementing them when Regan began
clinician perception of improvement were rated as to exhibit tearfulness and tantrums over “being uncom-
“Mostly true,” 27% of items were rated as “Somewhat fortable on the bed” (where the therapy session was
true,” and 18% of the items were rated as “Not at all held). Regan was able to de-escalate within 5 minutes
true.” An examination of the Step Up/Step Down Cli- of using her plan, which included using opposite
ent Questionnaire indicated that 64% of items assess- action to remain in the room and speak calmly, ask
ing client/parent perception of improvement were for a hug, and ask herself what a well-behaved peer
rated as “True to a great extent,” 18% were rated as would do. The clinician positively reinforced use of
“Mostly true,” and 18% were rated as “Not at all true,” the meltdown plan by instructing Regan’s mother to
including “My child and I are ready to terminate ther- provide her with coins. Following this in vivo frustra-
apy” and “My child feels that he or she no longer needs tion tolerance exposure, the clinician revisited the plan
therapy.” Although Regan’s top problems had all for step down after the current session. Regan’s mother
reduced in severity and her meltdowns had reduced agreed that she and Regan’s father felt that Regan
in frequency, Regan’s mother was hesitant to end ther- should step down, stating “we have all the skills . . .
apy because Regan’s meltdowns had not fully remitted. now we just need to be consistent and work at it.”
Additionally, she reported difficulty with consistently The severity of Regan’s top problems had all
using opposite parenting behaviors. Therefore, the decreased by termination, as illustrated by the follow-
clinician and family collaboratively decided to step up. ing ratings: (a) out-of-control meltdowns when cor-
 Transdiagnostic Stepped-Care Approach via Telehealth 359

rected (Regan rating = 5/8, 29% decrease from base- the family home after hurricane-related flooding and
line; mother rating = 4/8, 43% decrease from base- an extended displacement following flooding. Addi-
line), (b) negative self-talk during meltdowns (Regan tionally, Will’s mother had been involved in a car crash
rating = 0/8, 100% decrease from baseline; mother rat- from which she sustained serious injuries. Top prob-
ing = 4/8, 43% decrease from baseline), and (c) talk- lems identified by Will and his mother included (a)
ing back when given a command (Regan rating = irritable attitude (Will rating = 5/8, mother rating =
7/8, 13% decrease from baseline; mother rating = 8/8), (b) low self-confidence (Will rating = 4/8,
4/8, 50% decrease from baseline). However, many of mother rating = 6/8), and (c) difficulty expressing feel-
these top problems scores had not decreased from ings (Will and mother rating = 3/8).
the end of Step 1 to the end of Step 2, and several Will initially had some difficulty with psychoeduca-
had actually increased. Additionally, Regan’s question- tion about emotions provided in Session 1 of treat-
naire scores did not appear to decrease from baseline ment, such as struggling to distinguish body clues
to post-Step 2. Regan’s anxiety scores changed very lit- and emotions. Will’s opposite action experiments and
tle from BL to Post based on self-report (BL SCAS-C T exposures during Step 1 of treatment focused primarily
score = 50, Post SCAS-C T score = 48) and parent on exposures to frustrating situations and practice with
report (BL SCAS-P T score = 63, Post SCAS-P T score acting opposite to anger and frustration. As treatment
= 66). Scores on the SMFQ and SDQ either remained progressed, Will’s mother reported improvements in
stable or increased slightly (BL SMFQ-C raw score = Will’s distress tolerance, ability to handle criticism,
8, Post SMFQ-C raw score = 9; BL SMFQ-P raw score and expression of emotions. The opposite parenting
= 10, Post SMFQ-P raw score = 13; BL SDQ raw score behavior of “consistency” was introduced to Will’s
= 21, Post SDQ raw score = 27). Self-reported quality mother in the first session and reinforced throughout
of life also decreased slightly during treatment (BL Step 1 at treatment, as Will’s parents were divorced
PQ-LES-Q raw score = 59, Post PQ-LES-Q raw score = and his mother expressed difficulty with consistent
53). When the clinician discussed these scores with co-parenting with Will’s father. The clinician also
Regan’s mother following the end of Step 2, Regan’s noted inconsistency in the home environment during
mother expressed surprise and described many qualita- sessions, as Will’s mother had difficulty maintaining
tive improvements in Regan’s symptoms. materials, and sessions were often held in distractible
Regan’s case illustrates an example of how when environments (e.g., on Will’s bed). Nevertheless, Will
questionnaire results after Step 1 were equivocal, client continued to progress with frustration tolerance expo-
preferences were most strongly considered as a factor sures and did well with practice of present-moment
in the decision to step up or down. Notably, equivocal- awareness.
ity of results persisted in Step 2, with questionnaire and The Step Up/Step Down Questionnaire was com-
top problems data suggesting limited improvement as pleted by Will and his mother after Session 5 and dis-
a result of further treatment, but subjective client per- cussed with the clinician in Session 6, which was a
ceptions supporting termination. Regan’s case was parent phone support session. The severity of Will’s
notable for a shift in treatment targets across the first top problems had all decreased significantly, as illus-
six sessions, as well as for Regan’s mixed internaliz- trated by the following ratings: (a) irritable attitude
ing/externalizing symptom presentation. For these (Will and mother rating = 1/8, 80% decrease from
reasons, it is possible that a two-step model may have baseline for Will and 88% decrease from baseline for
been insufficient to fully address Regan’s differing mother), (b) low self-confidence (Will rating = 2/8,
symptom sets, and a third step may have been benefi- 50% decrease from baseline; mother rating = 1/8,
cial. Regan’s case also illustrates the difficulty of decid- 83% decrease from baseline), and (c) difficulty
ing how to prioritize qualitative versus quantitative expressing feelings (Will rating = 0/8, 100% decrease
information when making decisions about stepping from baseline; mother rating = 1/8, 67% decrease from
up or down in treatment. baseline). One hundred percent of items from the
Step Up/Step Down Clinician Questionnaire assessing
clinician perception of patient improvement and
Case 3: Step Down After Step 1, Low acquisition of skills were rated as being “Mostly true”
Clinician and Client Agreement About Step or “True to a great extent.” The clinician rated the item
Down “My client feels ready to terminate therapy” as “Some-
what srue” but indicated feeling it is “Mostly true” that
“Will” presented to treatment primarily for concerns “My client no longer needs therapy.” An examination
with irritability and frustration intolerance, which his of the Step Up/Step Down Client Questionnaire simi-
mother reportedly began to notice approximately 6 larly indicated that most items were rated by the parent
months prior to initiating treatment for Will. Will and child as “Mostly true” or “True to a great extent.”
had endured several highly stressful life events within However, Will’s mother rated the item “I feel as though
the past 2 years, including a forced evacuation from
360 Kennedy et al.

my child’s top problems have meaningfully improved” care model for treating emotional disorders in chil-
as only “Somewhat true,” as well as the item “My child dren using the UP-C (Ehrenreich-May et al., 2018).
has learned one or more strategies to solve or cope Stepped-care approaches to treating emotional disor-
with problems.” Will’s mother rated both the item ders in children may narrow the gap between children
“My child feels that he or she no longer needs therapy” in need of evidence-based treatments and those actu-
and the item “My child and I are ready to terminate ally receiving them, as they have been shown to reduce
therapy” as “Not at all true.” therapist time and cost required to provide mental
Based on decreased top problem ratings and posi- health services (Rapee et al., 2017; Salloum et al.,
tive clinician and family ratings of improvement and 2016). The UP-C is uniquely suited to a stepped-care
skills acquisition, the clinician recommended stepping format, as it presents evidence-supported intervention
down following Session 6, despite low readiness to ter- strategies in a transdiagnostic framework that can be
minate treatment reported by the family. Will’s mother applied to the wide range of presenting problems
agreed with the clinician’s assessment of Will’s progress and comorbidities commonly seen in community prac-
but reported reluctance to step down, explaining that tice settings (e.g., Southam-Gerow et al., 2003).
“Consistency has been an issue” with maintaining pro- The case studies presented in this paper illustrate
gress in the past. As Will’s mother was unable to iden- how UPC-SC can be flexibly applied to address the
tify further treatment goals at this point, the clinician wide range of emotional disorder symptoms with which
reinforced the recommendation for step down while children commonly present, including generalized
also normalizing ambivalence about termination. Will’s worry, adjustment symptoms, obsessions and compul-
mother eventually expressed understanding of and sions, frustration intolerance, and disruptive behavior
agreement with this recommendation, explaining symptoms. Although the conclusions that can be drawn
“Mom wants baby birds to fly on their own.” Will’s from a series of case studies such as that presented in
mother expressed some concern about how Will might this paper are limited, these cases do provide prelimi-
cope with the beginning of the next school year, nary support of the feasibility of UPC-SC in addressing
explaining that Will “is less mature than peers” and a range of emotional disorder concerns. Child and
“might have anxiety.” The clinician provided Will’s family satisfaction were high, with all families rating
mother with additional information regarding how to their satisfaction with the first five sessions as “true to
access services in the future, should Will need them. a great extent” on the Step Up/Step Down Question-
The clinician conducted a final flex session with the naire. Additionally, two of the three cases presented
family focused on thinking traps and an introduction in this paper responded sufficiently to treatment to
to flexible thinking prior to stepping down. step down following session 6. Visual inspection of data
Overall, Will experienced improvements in self- indicated that the two cases that stepped down after
reported mood (BL SMFQ-C raw score = 6, Post Session 6 (“Will” and “Nate”) exhibited decreased
SMFQ-C raw score = 2) and parent-reported mood scores on most outcome measures at posttreatment,
(BL SMFQ-P raw score = 11, Post SMFQ-P raw score = and posttreatment scores fell below suggested clinical
2). Scores on the SDQ improved slightly (BL SDQ cutoffs on all measures.
raw score = 19, Post SDQ raw score = 15). Little change Our initial experiences with piloting this mode of
was observed in either parent-reported anxiety (BL delivery yield insights into the strengths and challenges
SCAS-P T score = 61, Post SCAS-P T score = 59) or of treating children with emotional disorders using a
self-reported quality of life (BL PQ-LES-Q raw score = stepped-care model, as well as areas for future investi-
57, Post PQ-LES-Q raw score = 58). Self-reported anxi- gation. Evidence suggests that a significant proportion
ety scores were not available. Will’s case illustrates the of youth may benefit sufficiently from a lower-dose
difficulty of arriving at a step-up/step-down decision treatment (Mufson et al., 2018; Pettit et al., 2017;
when parent preferences are discrepant with clinician Salloum et al., 2016), and our approach allowed us to
judgment based on questionnaire data. When agree- identify clients who made significant gains early on in
ment is not readily reached, it may be difficult to treatment and may not have benefited from additional
decide whose perspective to prioritize, and clinicians services. In cases where there is high alignment among
may have difficulty discharging patients against their outcome measures and client/clinician subjective
wishes. Ultimately, by drawing attention to Will’s treat- impressions, the decision to step down to a lower inten-
ment progress, normalizing ambivalence about termi- sity treatment or no treatment at all may be a straight-
nation, and enhancing his mother’s self-efficacy, the forward one, as it was for Nate and his family. In Nate’s
clinician was able to move the family to termination. case, top problem ratings, questionnaire-reported pro-
gress and readiness to terminate, outcome measures,
Conclusion and subjective impressions from the clinician and fam-
ily all aligned. Decisions to step down may be more dif-
This treatment development paper describes the ficult in cases of modest but not overwhelming
development and initial delivery of a novel, stepped-
 Transdiagnostic Stepped-Care Approach via Telehealth 361

progress, as there are few clear guidelines for deter- ing UPC-SC as a telehealth intervention, results may
mining how much improvement is enough to warrant not be widely generalizable and should be replicated
treatment termination, particularly in the absence of with larger samples. Second, the same therapist pro-
information from structured diagnostic interviews. vided treatment to all three cases discussed in this
Step-down decisions may be doubly hard when study, which presents challenges for disentangling
improvement assessments are discrepant among raters, intervention effects from therapist effects. Although
and/or discrepant among measures, as it is unclear in the intentionally flexible format of UPC-SC enhanced
these cases whose ratings or which measurement the clinician’s ability to personalize the intervention,
method to prioritize. This decision becomes even more this flexibility limits our ability to draw conclusions
difficult in cases where clinician judgment is to termi- about which aspects of UPC-SC were effective for which
nate treatment based on outcome measures, while a families, especially in Step 2 during which interven-
patient and family strongly prefer to continue with tions were even more personalized. Relatedly, the flex-
treatment (as was the case with Will). Future studies ibility of our approach means that clinicians wanting to
on UPC-SC and other stepped-care interventions deliver the intervention would likely need training in
should empirically investigate whether top problem the full UP-C intervention, which may be prohibitively
ratings, subjective ratings of improvement, standard- resource intensive in some practice settings. Efforts are
ized measures, or their combination best inform deci- under way to develop more streamlined and online
sions about whether to step up or down and best training processes to facilitate widespread dissemina-
align with treatment response and remission. Our tion of the UP-C for both stepped-care and standard
experience has been that use of motivational enhance- approaches. An ongoing pilot study will inform the
ment techniques and interventions promoting parent development of a more standardized curriculum for
self-efficacy were helpful in resolving conflicts and dis- UPC-SC, as well as efforts to develop sequencing algo-
crepancies in the step-up/step-down process, and we rithms for personalizing the intervention. Additionally,
believe it may be helpful for these approaches to be although both standardized and ideographic measures
standardized as part of the step-up/step-down were administered, and although rough guidelines
decision-making process. were developed to inform decisions about stepping
Regarding our telehealth mode of delivery, this case up or down, a collaborative decision-making process
series both supported the initial feasibility of delivering heavily influenced by client preferences ultimately
UPC-SC via telehealth and also revealed some chal- drove decisions about whether families progressed to
lenges related to telehealth implementation. Tele- Step 2 of treatment. Future work on UPC-SC will focus
health delivery enhanced the ability of the clinician on better operationalizing how outcome measures will
to conduct exposures and encourage opposite actions be integrated into a collaborative decision-making
to strong emotions in the home environment, where approach, particularly in cases where there is clini-
many problematic behaviors often occurred. Conduct- cian–client disagreement about the next step of
ing exposures in typical environments and multiple treatment.
contexts has been suggested as a way of increasing Despite these limitations and areas for further devel-
the efficacy of exposure (Craske et al., 2014), as opment, UPC-SC shows early promise for flexibly
opposed to solely in the clinic space where it may be addressing a variety of emotional disorder concerns
difficult to simulate real-world environments. Atten- in an abbreviated treatment format that is acceptable
dance and compliance were also high for all three par- to clinicians and families. Implementation and dissem-
ticipants, which may reflect reduced transportation ination of transdiagnostic, stepped-care approaches to
and scheduling burdens associated with telehealth emotional disorders in children such as UPC-SC has
delivery. However, several barriers to effective tele- the potential to increase efficiency of mental health
health delivery were encountered in this trial, includ- treatment, enhance accessibility, and reduce costs of
ing difficulty maintaining a therapeutic environment mental health treatment, as previous stepped-care
in the home. Sessions often took place on the child’s approaches have demonstrated. Ongoing research
bed due to lack of other feasible spaces, and some efforts are being conducted to refine UPC-SC and
home environments were messy, chaotic, or busy. Dis- examine efficacy in a larger sample.
cussion of establishing a therapeutic environment in
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Funding: This project received through a grant awarded to the
Spence, S. H. (1998). A measure of anxiety symptoms among
last author from the ReBuild Texas Fund.
children. Behaviour Research and Therapy, 36(5), 545–566.
Stewart, R. W., Orengo-Aguayo, R. E., Cohen, J. A., Mannarino, A.
Disclosure Statement: Sarah Kennedy and Jill Ehrenreich-May
P., & de Arellano, M. A. (2017). A pilot study of trauma-focused receive compensation for providing training and consultation on
cognitive-behavioral therapy delivered via telehealth technology. the Unified Protocols for Transdiagnostic Treatment of Emo-
Child Maltreatment, 22(4), 324–333. tional Disorders in Children and Adolescents. Ehrenreich-May
Storch, E. A., Caporino, N. E., Morgan, J. R., Lewin, A. B., Rojas, A., also receives royalties from the sale of these treatment manuals.
Brauer, L., ... Murphy, T. K. (2011). Preliminary investigation of Address correspondence to Sarah M. Kennedy, Ph.D., University
web-camera delivered cognitive-behavioral therapy for youth of Colorado School of Medicine, 13123 East 16th Avenue, B130,
with obsessive-compulsive disorder. Psychiatry Research, 189(3), Aurora, CO 80045 e-mail: [email protected].
407–412.
Stringaris, A., Vidal-Ribas, P., Brotman, M. A., & Leibenluft, E. Received: August 9, 2019
(2018). Practitioner review: Definition, recognition, and Accepted: June 8, 2020
treatment challenges of irritability in young people. Journal of Available online 18 July 2020
Child Psychology and Psychiatry, 59(7), 721–739.