Sonja March

The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety

Seventy-two clinically anxious children, aged 7 to 14 years, were randomly allocated to clinic-based, cognitive-behavior therapy, the same treatment partially delivered via the Internet, or a wait-list control (WL). Children in the clinic and clinic-plus-Internet conditions showed significantly greater reductions in anxiety from pre- to posttreatment and were more likely to be free of their anxiety diagnoses, compared with the WL group. Improvements were maintained at 12-month follow-up for both therapy conditions, with minimal difference in outcomes between interventions. The Internet treatment content was highly acceptable to families, with minimal dropout and a high level of therapy compliance.

The Efficacy of an Internet-Based Cognitive-Behavioral Therapy Intervention for Child Anxiety Disorders

OBJECTIVE To evaluate the efficacy of an Internet-based cognitive-behavioral therapy (CBT) approach to the treatment of child anxiety disorders. METHODS Seventy-three children with anxiety disorders, aged 7-12 years, and their parents were randomly assigned to either an Internet-based CBT (NET) or wait-list (WL) condition. Clinical diagnostic assessment and parent and child questionnaires were completed before and after treatment. The NET condition was reassessed at 6-month follow-up. RESULTS At posttreatment assessment, children in the NET condition showed small but significantly greater reductions in anxiety symptoms and increases in functioning than WL participants. These improvements were enhanced during the 6-month follow-up period, with 75% of NET children free of their primary diagnosis. CONCLUSIONS Internet delivery of CBT for child anxiety offers promise as a way of increasing access to treatment for this population. Future research is needed to examine ways to increase treatment compliance and further enhance the impact of treatment.

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)

Online CBT for preschool anxiety disorders: a randomised control trial.

UNLABELLED The aim of this study was to investigate the efficacy of an internet-based, therapist assisted, parent-focussed, CBT program for preschoolers with anxiety disorders. Fifty-two children aged 3-6 years were randomly allocated into internet treatment (NET) and waitlist control (WLC) groups. Parents completed diagnostic interviews and online questionnaires at pre-treatment, post-treatment and 6-month follow-up. Results at post-treatment showed a significantly greater reduction in clinical severity, anxiety symptoms and internalising behaviour, as well as a greater increase in overall functioning for children in the NET compared to the WLC condition. However, group differences were not evident from pre- to post-treatment on the percentages of children who lost their primary anxiety diagnosis or who lost all anxiety diagnoses. At post-treatment for the completer sample, 39.1% of the NET children compared to 25.9% of the WLC were free of their primary diagnosis. At 6-month follow-up, treatment gains were maintained in the case of overall functioning and further improved upon with respect to clinical severity, anxiety symptoms and internalising behaviour. By 6-month follow-up for the completer sample, 70.6% of children were free of their primary diagnosis. The results suggest that an internet program for preschool anxiety is feasible, efficacious and well received by parents. AUSTRALIAN CLINICAL TRIAL REGISTRATION NUMBER ACTRN12612000139875.

Protocol for a randomised controlled trial of risk screening and early intervention comparing child- and family-focused cognitive-behavioural therapy for PTSD in children following accidental injury

BackgroundAccidental injury represents the most common type of traumatic event to which a child or adolescent may be exposed, with a significant number of these children going on to experience posttraumatic stress disorder (PTSD). However, very little research has examined potential interventions for the treatment of PTSD in these children. The present trial aims to evaluate and compare child- and family-focused versions of a cognitive-behavioural early intervention for PTSD following accidental injury.Methods/DesignThe principal clinical question under investigation is the efficacy of an early, trauma-focused cognitive-behavioural intervention for the treatment of PTSD in children following accidental injury. Specifically, we compare the efficacy of two active treatments (child-focused and family-focused CBT) and a waitlist control (no therapy) to determine which is associated with greater reductions in psychological and health-related outcome measures over time. The primary outcome will be a reduction in trauma symptoms on a diagnostic interview in the active treatments compared to the waitlist control and greater reductions in the family-compared to the child-focused condition. In doing so, this project will also trial a method of stepped screening and assessment to determine those children requiring early intervention for PTSD following accidental injury.DiscussionThe present trial will be one of the first controlled trials to examine a trauma-focused CBT, early intervention for children experiencing PTSD following accidental injury (as opposed to other types of traumatic events) and the first within a stepped care approach. In addition, it will provide the first evidence comparing the efficacy of child and family-focused interventions for this target group. Given the significant number of children and adolescents exposed to accidental injury, the successful implementation of this protocol has considerable implications. If efficacious, this early intervention will assist in reducing symptoms of traumatic stress as well as preventing chronic disorder and disability in children experiencing acute PTSD following accidental injury.Trial RegistrationControlled-trials.com: ISRCTN79049138

The efficacy of a group-based, disorder-specific treatment program for childhood GAD--a randomized controlled trial.

The aim of this study was to provide a preliminary examination of a disorder-specific treatment program for children with generalised anxiety disorder (GAD) that employed strategies targeting underlying cognitive factors. Forty-two children with a primary diagnosis of GAD, aged between 7 and 12 years, were randomly assigned to either a treatment (TX) or waitlist (WLC) condition. Clinical diagnostic interviews as well as parent and child questionnaires were completed at pre- and post-assessment for both conditions, and at 3-month follow-up for the TX group. For the completer analyses at post-treatment, 52.9 % of children in the TX group (0% in the WLC group) were free of their primary GAD diagnosis. By 3-month follow-up, 100% of children in the TX group were free of their GAD diagnosis, 50% were free of all diagnoses. Overall, there is preliminary evidence that a disorder-specific treatment program for children with GAD is effective in treating this chronic and disabling disorder.

Using a web-based game to prevent posttraumatic stress in children following medical events: design of a randomized controlled trial

Background Medical events including acute illness and injury are among the most common potentially traumatic experiences for children. Despite the scope of the problem, only limited resources are available for prevention of posttraumatic stress symptoms (PTSS) after pediatric medical events. Web-based programs provide a low-cost, accessible means to reach a wide range of families and show promise in related areas of child mental health. Objectives To describe the design of a randomized controlled trial that will evaluate feasibility and estimate preliminary efficacy of Coping Coach, a web-based preventive intervention to prevent or reduce PTSS after acute pediatric medical events. Method Seventy children and their parents will be randomly assigned to either an intervention or a waitlist control condition. Inclusion criteria require that children are aged 8–12 years, have experienced a medical event, have access to Internet and telephone, and have sufficient competency in the English language to complete measures and understand the intervention. Participants will complete baseline measures and will then be randomized to the intervention or waitlist control condition. Children in the intervention condition will complete module 1 (Feelings Identification) in the hospital and will be instructed on how to complete modules 2 (Appraisals) and 3 (Avoidance) online. Follow-up assessments will be conducted via telephone at 6, 12, and 18 weeks after the baseline assessment. Following the 12-week assessment, children in the waitlist control condition will receive instructions for completing the intervention. Results Primary study outcomes include data on intervention feasibility and outcomes (child appraisals, coping, PTSS and health-related quality of life). Discussion Results will provide data on the feasibility of the implementation of the Coping Coach intervention and study procedures as well as estimations of efficacy to determine sample size for a larger study. Potential strengths and limitations of this design are discussed.

Involving Parents in Indicated Early Intervention for Childhood PTSD Following Accidental Injury

Accidental injuries represent the most common type of traumatic event to which a youth is likely to be exposed. While the majority of youth who experience an accidental injury will recover spontaneously, a significant proportion will go on to develop Post-Traumatic Stress Disorder (PTSD). And yet, there is little published treatment outcome research in this area. This review focuses on two key issues within the child PTSD literature—namely the role of parents in treatment and the timing of intervention. The issue of parental involvement in the treatment of child PTSD is a question that is increasingly being recognized as important. In addition, the need to find a balance between providing early intervention to at risk youth while avoiding providing treatment to those youth who will recover spontaneously has yet to be addressed. This paper outlines the rationale for and the development of a trauma-focused CBT protocol with separate parent and child programs, for use with children and adolescents experiencing PTSD following an accidental injury. The protocol is embedded within an indicated intervention framework, allowing for the early identification of youth at risk within a medical setting. Two case studies are presented in order to illustrate key issues raised in the review, implementation of the interventions, and the challenges involved.