Samantha J. Prosser

A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety

OBJECTIVE The study examined the relative efficacy of online (NET) versus clinic (CLIN) delivery of cognitive behavior therapy (CBT) in the treatment of anxiety disorders in adolescents. METHOD Participants included 115 clinically anxious adolescents aged 12 to 18 years and their parent(s). Adolescents were randomly assigned to NET, CLIN, or wait list control (WLC) conditions. The treatment groups received equivalent CBT content. Clinical diagnostic interviews and questionnaire assessments were completed 12 weeks after baseline and at 6- and 12-month follow-ups. RESULTS Assessment at 12 weeks post-baseline showed significantly greater reductions in anxiety diagnoses and anxiety symptoms for both NET and CLIN conditions compared with the WLC. These improvements were maintained or further enhanced for both conditions, with minimal differences between them, at 6- and 12-month follow-ups. Seventy-eight percent of adolescents in the NET group (completer sample) no longer met criteria for the principal anxiety diagnosis at 12-month follow-up compared with 80.6% in the CLIN group. Ratings of treatment credibility from both parents and adolescents were high for NET and equivalent to CLIN. Satisfaction ratings by adolescents were equivalent for NET and CLIN conditions, whereas parents indicated slightly higher satisfaction ratings for the CLIN format. CONCLUSIONS Online delivery of CBT, with minimal therapist support, is equally efficacious as clinic-based, face-to-face therapy in the treatment of anxiety disorders among adolescents. This approach offers a credible alternative to clinic-based therapy, with benefits of reduced therapist time and greater accessibility for families who have difficulty accessing clinic-based CBT.

Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE-ONLINE and two case illustrations.

This paper describes the rationale for and development of an online cognitive-behavioural treatment for child and adolescent anxiety (BRAVE–ONLINE). It highlights the challenges involved in adapting a clinic-based intervention for delivery using the internet, with separate sessions for parents and their children (or adolescents). We outline strategies to ensure that young people remain engaged in online therapy, and describe techniques designed to optimize the alliance between clients and the online therapist. Two case studies are presented that illustrate the practical and technical aspects of implementing the intervention, and demonstrate the feasibility of achieving successful outcomes using online delivery of CBT for child and adolescent anxiety. However, firm conclusions regarding the efficacy of this approach cannot be drawn until the results of randomized controlled trials are available. The paper identifies directions for future research.

Working alliance in online cognitive behavior therapy for anxiety disorders in youth: comparison with clinic delivery and its role in predicting outcome

Background Substantial evidence exists that positive therapy outcomes are related to the therapist–client working alliance. Objectives To report two studies that examined (1) the quality of the working alliance in online cognitive behavior therapy (CBT), with minimal therapist contact, for anxiety disorders in youth, and (2) the role of working alliance and compliance in predicting treatment outcome. Methods Study 1 participants were 73 adolescents aged 12 to 18 years who met diagnostic criteria for an anxiety disorder, plus one or more of their parents. Participants were randomly assigned to clinic or online delivery of CBT, with working alliance being assessed for youth and parents after session 3. Study 2 participants were 132 children and adolescents aged 7 to 18 years who met diagnostic criteria for an anxiety disorder, plus one or more of their parents. Youths and parents participated in a minimally therapist-assisted online CBT program supported by brief, weekly emails and a single, short phone call. Results Study 1 revealed a strong working alliance for both online and clinic CBT, with no significant difference in working alliance between conditions for adolescents (F 1,73 = 0.44, P = .51, ηp 2 = 0.006, Cohen d = 0.15). Parents also reported high working alliance in both conditions, although a slight but significantly higher working alliance in clinic-based therapy (F 1,70 = 6.76, P = .01, ηp 2 = 0.09, Cohen d = 0.64). Study 2 showed a significant and substantial decrease in anxiety symptoms following online therapy (P < .001 for all outcome measures). Adolescents improved significantly more in overall functioning when working alliance (beta = .22, t 79 = 2.21, P = .03) and therapy compliance (beta = .22, t 84 = 2.22, P = .03) were higher, with working alliance also predicting compliance (beta = .38, F 1,80 = 13.10, P = .01). No such relationships were evident among younger children. Conclusions Working alliance is important in determining clinical outcome for online treatment for anxiety among adolescents, with minimal therapist assistance, although this was not the case for younger children. Trial Registration Australian New Zealand Clinical Trials Registry: ACTRN12611000900910; http://www.anzctr.org.au/trial_view.aspx?ID=343375 (Archived by WebCite at http://www.webcitation.org/674C4N3JJ)

What women want: qualitative analysis of consumer evaluations of maternity care in Queensland, Australia

BackgroundMaternity care reform plans have been proposed at state and national levels in Australia, but the extent to which these respond to maternity care consumers’ expressed needs is unclear. This study examines open-text survey comments to identify women’ss unmet needs and priorities for maternity care. It is then considered whether these needs and priorities are addressed in current reform plans.MethodsWomen who had a live single or multiple birth in Queensland, Australia, in 2010 (n 3,635) were invited to complete a retrospective self-report survey. In addition to questions about clinical and interpersonal maternity care experiences from pregnancy to postpartum, women were asked an open-ended question “Is there anything else you’d like to tell us about having your baby?” This paper describes a detailed thematic analysis of open-ended responses from a random selection of 150 women (10% of 1,510 who responded to the question).ResultsFour broad themes emerged relevant to improving women’s experiences of maternity care: quality of care (interpersonal and technical); access to choices and involvement in decision-making; unmet information needs; and dissatisfaction with the care environment. Some of these topics are reflected in current reform goals, while others provide evidence of the need for further reforms.ConclusionsThe findings reinforce the importance of some existing maternity reform objectives, and describe how these might best be met. Findings affirm the importance of information provision to enable informed choices; a goal of Queensland and national reform agendas. Improvement opportunities not currently specified in reform agendas were also identified, including the quality of interpersonal relationships between women and staff, particular unmet information needs (e.g., breastfeeding), and concerns regarding the care environment (e.g., crowding and long waiting times).

Going public: Do risk and choice explain differences in caesarean birth rates between public and private places of birth in Australia?

BACKGROUND women who birth in private facilities in Australia are more likely to have a caesarean birth than women who birth in public facilities and these differences remain after accounting for sector differences in the demographic and health risk profiles of women. However, the extent to which womens preferences and/or freedom to choose their mode of birth further account for differences in the likelihood of caesarean birth between the sectors remains untested. METHOD women who birthed in Queensland, Australia during a two-week period in 2009 were mailed a self-report survey approximately 3 months after birth. Seven hundred and fifty-seven women provided cross-sectional retrospective data on where they birthed (public or private facility), mode of birth (vaginal or caesarean) and risk factors, along with their preferences and freedom to choose their mode of birth. A hierarchical logistic regression was conducted to determine the extent to which maternal risk and freedom to choose ones mode of birth explain sector differences in the likelihood of having a caesarean birth. FINDINGS while there was no sector difference in womens preference for mode of birth, women who birthed in private facilities had higher odds of feeling able to choose either a vaginal or caesarean birth, and feeling able to choose only a caesarean birth. Women had higher odds of having caesarean birth if they birthed in private facilities, even after accounting for significant risk factors such as age, body mass index, previous caesarean and use of assisted reproductive technology. However, there was no association between place of birth and odds of having a caesarean birth after also accounting for freedom to choose ones mode of birth. CONCLUSIONS these findings call into question suggestions that the higher caesarean birth rate in the private sector in Australia is attributable to increased levels of obstetric risk among women birthing in the private sector or maternal preferences alone. Instead, the determinants of sector differences in the likelihood of caesarean births are complex and are linked to differences in the perceived choices for mode of birth between women birthing in the private and public systems.

Why 'down under' is a cut above: a comparison of rates of and reasons for caesarean section in England and Australia

BackgroundMost studies examining determinants of rising rates of caesarean section have examined patterns in documented reasons for caesarean over time in a single location. Further insights could be gleaned from cross-cultural research that examines practice patterns in locations with disparate rates of caesarean section at a single time point.MethodsWe compared both rates of and main reason for pre-labour and intrapartum caesarean between England and Queensland, Australia, using data from retrospective cross-sectional surveys of women who had recently given birth in England (n = 5,250) and Queensland (n = 3,467).ResultsWomen in Queensland were more likely to have had a caesarean birth (36.2%) than women in England (25.1% of births; OR = 1.44, 95% CI = 1.28-1.61), after adjustment for obstetric characteristics. Between-country differences were found for rates of pre-labour caesarean (21.2% vs. 12.2%) but not for intrapartum caesarean or assisted vaginal birth. Compared to women in England, women in Queensland with a history of caesarean were more likely to have had a pre-labour caesarean and more likely to have had an intrapartum caesarean, due only to a previous caesarean. Among women with no previous caesarean, Queensland women were more likely than women in England to have had a caesarean due to suspected disproportion and failure to progress in labour.ConclusionsThe higher rates of caesarean birth in Queensland are largely attributable to higher rates of caesarean for women with a previous caesarean, and for the main reason of having had a previous caesarean. Variation between countries may be accounted for by the absence of a single, comprehensive clinical guideline for caesarean section in Queensland.

Measuring women’s experience of induction of labor using prostaglandin vaginal gel

OBJECTIVE To describe and examine the EXIT (EXperiences of Induction Tool), and report on the experience of women undergoing PGE2 vaginal gel IOL, who were participants in a randomized controlled trial comparing early amniotomy with repeat-PGE2. STUDY DESIGN Following an evening dose of PGE2 vaginal gel, 245 women with live singleton term pregnancies were randomized to amniotomy or repeat-PGE2. Womens experience of IOL was a secondary outcome measure, assessed using the self-report EXIT administered by phone at 7-9days post-partum. The 10-item EXIT assessed womens experiences in multiple domains using a 5-point agreement scale. Principal components analysis with orthogonal varimax rotation was undertaken to examine the scale structure. Internal consistency, face, content, construct and discriminant validity were also assessed. RESULTS The final 3-component solution comprised 8 of the 10 EXIT items, explained 76.1% of the variance and had a good fit to model (p<0.001). The three resulting components were representative of womens experience of the time taken to give birth, discomfort with IOL, and subsequent contractions. The items loading to each component showed good internal consistency for time taken to give birth (α=0.88), discomfort with IOL (α=0.78), and experience of subsequent contractions (α=0.87). Women in the repeat-PGE2 group reported a less favorable experience with the time taken to give birth (mean (SD): 3.5 (1.4) vs 3.9 (1.2); p=0.04) and more discomfort with IOL (2.9 (1.1) vs 2.5 (1.0); p=0.04) compared to women in the amniotomy group. At the individual item level, women in the amniotomy group responded more positive about the time taken to have their baby (median (IQR): 4 (3-5) vs 3 (2-5); p<0.01); and less negative to the question about the number of vaginal examinations (2 (1-3) vs 2 (1-4); p=0.05). CONCLUSIONS The EXIT shows promise as an instrument for assessing womens experience of IOL. Women undergoing PGE2 vaginal gel IOL reports a more positive experience with an early amniotomy rather than with repeat-PGE2.