Table 3.

Loops.

Loop pattern	Loop name	Loop description	Potential solutions
Dashes	Search & Outreach Loop	• Repeated process of getting a name of a potential therapist and running into barriers to scheduling an appointment with them	• More resources at children’s schools (e.g., guidance counselors who know what exposure is, can teach parents skills, and provide referrals or exposure treatment) (parent-generated solution)
		• Requires substantial time from parents to seek services for their child (e.g., due to phone calls, timing of available appointments)	• More transparency and up-to-date information about referrals from insurance companies and professional organizations (researcher-generated solution)
			• Increase availability of lower intensity interventions (e.g., psychoeducation, assessment, phone consultation, single session interventions) (researcher-generated solution)
Alternating Dashes and Dots	Medical Loop	• Presence of comorbid medical conditions OR medical symptoms (e.g., gastrointestinal distress, PANDAS, low weight due to anxiety/OCD symptoms) requires initial diagnosis and treatment by medical provider	• Dissemination of information and training for medical professionals, especially pediatricians, about anxiety/OCD assessment and exposure therapy (parent-generated solution)
		• Some children present to emergency room or medical provider for symptoms that can primarily be explained by anxiety/OCD, but may not be diagnosed accurately	• Integrated care teams that involve coordination with medical providers (specialists and pediatricians) and mental health providers (psychologists, psychiatrists, counselors) (researcher-generated solution)
		• Frequent visits to pediatricians for help with anxiety and associated medical symptoms
Small Dots	Parent research Loop	• After difficulty accessing appropriate treatment, parents did their own research into their child’s symptoms and possible treatments	• Dissemination of information about anxiety, OCD, and exposure therapy for parents (parent-generated solution)
		• Parents (and adolescents) looked up information online and called local clinics/hospitals for information	• Development of educational materials, such as podcasts and toolkits, geared toward parents to help recognize symptoms of anxiety and OCD (parent-generated solution)
		• Parents learned about exposure therapy, which led them back to looking for potential referrals	• Parent support groups, especially opportunities for families waiting for treatment to talk to families who have already done exposure (parent-generated solution)
			• Media promotion of exposure therapy (e.g., via television and radio commercials) (researcher-generated solution)
			• Psychoeducation about accommodation / importance of approach behaviors while waiting for treatment to give parents guidance on what to do (researcher-generated solution)