Background: There are a lack of clear guidelines for the dissemination of Internet-based cognitive behaviour therapy (ICBT) for childhood and adolescent anxiety in routine care. Whilst self-guided ICBT has greater reach than therapist-guided ICBT, it is plagued by problems of low program adherence and many young people are not successfully treated. It is important that we identify models of ICBT that are accessible, but provide the right support, at the right time to those who need it. Stepped-care models of ICBT offer one potential solution.
Objective: This case study examined the application of stepped-care within an ICBT intervention for childhood and adolescent anxiety, in which young people were stepped up from self-guided to therapist-guided ICBT.
Methods: Three case studies are presented and include young males (aged 11-12 years) who participated in BRAVE Stepped-Care, a new ICBT program incorporating two treatment steps: Step 1 – five sessions of self-guided ICBT and Step 2 – five sessions of therapist- guided ICBT. Participants completed diagnostic assessments at pre- and post-treatment, along with a battery of self-report questionnaires. Step-up requirements were determined at a mid- treatment assessment. Treatment response was determined by change on diagnostic severity and presence of diagnosis and changes in self-reported anxiety symptoms (through T-scores and Reliable Change Indices).
Results: In-depth examination of the three case studies showed that decisions to step-up from Step 1 to Step 2 were complex and required consideration of program engagement and adherence, as well as changes on self-reported anxiety, behavioural indicators of anxiety and parent perspectives. Results showed that non-responders at mid-treatment who were stepped- up to therapist-guided ICBT after Step 1 were able to increase engagement and response to treatment in Step 2, such that they were free of their primary anxiety diagnosis at post- treatment.
Conclusions: The findings highlight the importance of early assessment of engagement and non-response within self-guided ICBT programs for youth anxiety and the positive changes that can subsequently occur when therapist-guidance is introduced mid-treatment for non- responders. The efficacy of stepped-care ICBT models needs to be confirmed in larger randomised controlled trials.
Albano, A. M. & Silverman, W. K. 1996. The Anxiety Disorders Interview Schedule for Children for DSM-IV: Clinician manual (child and parent versions). San Antonio, TX, Psychological Corporation.
Andersson, G. & Titov, N. 2014. Advantages and limitations of Internet-based interventions for common mental disorders. World Psychiatry, 13, 4-11.
Arendt, K., Hougaard, E. & Thastum, M. 2014. Psychometric properties of the child and parent versions of SpenceChildren’s Anxiety Scale in a Danish community and clinical sample. Journal of Anxiety Disorders, 947-956.
Cobham, V., March, S., De Young, A., Leeson, F., Nixon, R., McDermott, B., & Kenardy, J. 2012. Involving Parents in Indicated Early Intervention for Childhood PTSD Following Accidental Injury. Clinical Child and Family Psychology Review, 15, 345- 363.
Costello, J., E, , He, J., Sampson, N., Kessler, R. & Merikangas, K. 2014. Services for Adolescents With Psychiatric Disorders: 12-Month Data From the National Comorbidity Survey–Adolescent. Psychiatric Services, 65, 359-366.
Donovan, C. L., Spence, S. H. & March, S. 2016. Does an Online CBT Program for Anxiety Impact Upon Sleep Problems in Anxious Youth? Journal of Clinical Child & Adolescent Psychology, 46, 211-221.
Hill, C., Creswell, C., Vigerland, S., Nauta, M. H., March, S., Donovan, C., Wolters, L., Spence, S. H., Martin, J. L., Wozney, L., Mclellan, L., Kreuze, L., Gould, K., Jolstedt, M., Nord, M., Hudson, J. L., Utens, E., Ruwaard, J., Albers, C., Khanna, M., Albano, A. M., Serlachius, E., Hrastinski, S. & Kendall, P. C. 2018. Navigating the development and dissemination of internet cognitive behavioral therapy (iCBT) for anxiety disorders in children and young people: A consensus statement with recommendations from the #iCBTLorentz Workshop Group. Internet Interventions, 12, 1-10.
Jacobson, N. S. & Truax, P. 1991. Clinical Significance: A Statistical Approach to Defining Meaningful Change in Psychotherapy Research. Journal of Consulting and Clinical Psychology, 59, 12-19.
Jolstedt, M., Wahlund, T., Lenhard, F., Ljótsson, B., Mataix-Cols, D., Nord, M., Öst, L.-G., Högström, J., Serlachius, E. & Vigerland, S. 2018. Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial. The Lancet Child & Adolescent Health, 2, 792-801.
Kazdin, A. E. 2019. Single-case experimental designs. Evaluating interventions in research and clinical practice. Behaviour Research and Therapy, 117, 3-17.
Lawrence, D., Johnson, S., Hafekost, J., Boterhoven De Haan, K., Sawyer, M., Ainley, J. & Zubrick, S. R. 2015. The Mental Health of Children and Adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Cabverra: Department of Health.
Lyneham, H. J., Sburlati, E. S., Abbott, M. J., Rapee, R. M., Hudson, J. L., Tolin, D. F. & Carlson, S. E. 2013. Psychometric properties of the Child Anxiety Life Interference Scale (CALIS). Journal of Anxiety Disorders, 27, 711-719.
March, S., Spence, S. H. & Donovan, C. L. 2009. The Efficacy of an Internet-Based Cognitive-Behavioral Therapy Intervention for Child Anxiety Disorders. Journal of Pediatric Psychology, 34, 474-487.
March, S., Spence, S. H., Donovan, C. L. & Kenardy, J. A. 2018. Large-Scale Dissemination of Internet-Based Cognitive Behavioral Therapy for Youth Anxiety: Feasibility and Acceptability Study. J Med Internet Res, 20, e234.
Merry, S. N., Stasiak, K., Shepherd, M., Frampton, C., Fleming, T. & Lucassen, M. F. 2012. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ, 344, e2598.
Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H. & Waters, A. 2004. A parent-report measure of children’s anxiety: psychometric properties and comparison with child-report in a clinic and normal sample. Behaviour Research and Therapy, 42, 813-839.
Pennant, M. E., Loucas, C. E., Whittington, C., Creswell, C., Fonagy, P., Fuggle, P., Kelvin, R., Naqvi, S., Stockton, S. & Kendall, T. 2015. Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behaviour Research and Therapy, 67, 1-18.
Podina, I. R., Mogoase, C., David, D., Szentagotai, A. & Dobrean, A. 2015. A Meta-Analysis on the Efficacy of Technology Mediated CBT for Anxious Children and Adolescents. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 34, 31-50.
Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A. & Rohde, L. A. 2015. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry, 56, 345-65.
Rapee, R. M., Lyneham, H. J., Wuthrich, V., Chatterton, M. L., Hudson, J. L., Kangas, M. & Mihalopoulos, C. 2017. Comparison of Stepped Care Delivery Against a Single, Empirically Validated Cognitive-Behavioral Therapy Program for Youth With Anxiety: A Randomized Clinical Trial. J Am Acad Child Adolesc Psychiatry, 56, 841- 848.
Rapee, R. M., Wignall, A., Hudson, J. L. & Schniering, C. A. 2000. Treating anxious children and adolescents: An evidence-based approach, Oakland, CA, US, New Harbinger Publications.
Rey, J. M., Starling, J., Wever, C., Dossetor, D. R. & Plapp, J. M. 1995. Inter‐ rater reliability of global assessment of functioning in a clinical setting. Journal of Child Psychology and Psychiatry, 36, 787-792.
Salloum, A., Scheeringa, M. S., Cohen, J. A. & Storch, E. A. 2014. Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children. Cognitive Behaviour Practice, 21, 97-108.
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H. & Aluwahlia, S. 1983. A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.
Spence, S. H. 1998. A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545-566.
Spence, S. H., Barrett, P. M. & Turner, C. M. 2003. Psychometric properties of the Spence Children’s Anxiety Scale with young adolescents. Journal of Anxiety Disorders, 17, 605-625.
Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S. & Kenardy, J. 2011. A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79, 629-642.
Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., Kercher, A., & Kenardy, J. 2008. Online CBT in the Treatment of Child and Adolescent Anxiety Disorders: Issues in the Development of BRAVE-ONLINE and Two Case Illustrations. Behavioural and Cognitive Psychoterhapy, 36, 411-430.
Spence, S. H., Holmes, J. M., March, S. & Lipp, O. V. 2006. The Feasibility and Outcome of Clinic Plus Internet Delivery of Cognitive-Behavior Therapy for Childhood Anxiety. Journal of Consulting and Clinical Psychology, 74, 614-621.
Spence, S. H., Sawyer, M. G., Sheffield, J., Patton, G., Bond, L., Graetz, B. & Kay, D. 2014. Does the absence of a supportive family environment influence the outcome of a universal intervention for the prevention of depression? International Journal of Environmental Research and Public Health, 11, 5113-5132.
Stallard, P., Udwin, O., Goddard, M. & Hibbert, S. 2007. The Availability of Cognitive Behaviour Therapy Within Specialist Child and Adolescent Mental Health Services (CAMHS): A National Survey. Behavioural and Cognitive Psychotherapy, 35, 501- 505.
Sweeney, G. M., Donovan, C. L., March, S. & Forbes, Y. 2017. Logging into therapy: Adolescent perceptions of computer-based therapies for mental health problems. Internet Interventions.
Sweeney, G. M., Donovan, C. L., March, S. & Laurenson, S. D. 2015. Logging into therapy: Parent attitudes and intentions to use computer-based therapies for youth mental health. Internet Interventions, 2, 437-445.
Tolin, D. F., Diefenbach, G. J. & Gilliam, C. M. 2011. Stepped care versus standard Cognitive-Behavioral Therapy for obsessive-compulsive disorder: A preliminary study of efficacy and costs. Depression & Anxiety 28, 314-323.
Topooco, N., Riper, H., Araya, R., Berking, M., Brunn, M., Chevreul, K., Cieslak, R., Ebert, D. D., Etchmendy, E., Herrero, R., Kleiboer, A., Krieger, T., García-Palacios, A., Cerga-Pashoja, A., Smoktunowicz, E., Urech, A., Vis, C. & Andersson, G. 2017. Attitudes towards digital treatment for depression: A European stakeholder survey. Internet Interventions, 8, 1-9.
Treffers, P. D. A. & Silverman, W. K. 2000. Anxiety and its disorders in children and adolescents before the twentieth century. In: Treffers, P. D. A. & Silverman, W. K. (eds.) Anxiety Disorders in Children and Adolescents: Research, Assessment and Intervention. Cambridge: Cambridge University Press.
Van Der Leeden, A. J. M., Van Der Leeden, R., Liber, J. M., Utens, E. M. W. J. & Treffers, P. D. A. 2011. Stepped Care Cognitive Behavioural Therapy for Children with Anxiety Disorders: A New Treatment Approach. Behavioural and Cognitive Psychotherapy, 39, 55-75.
Van Straten, A., Hill, J., Richards, D. A. & Cuijpers, P. 2015. Stepped care treatment delivery for depression: a systematic review and meta-analysis. Psychological Medicine, 45, 231-246.
Vigerland, S., Serlachius, E., Thulin, U., Andersson, G., Larsson, J. & Ljótsson, B. 2017. Long-term outcomes and predictors of internet-delivered cognitive behavioral therapy for childhood anxiety disorders. Behaviour Research & Therapy, 90, 67-75.
Warwick, H., Reardon, T., Cooper, P., Murayama, K., Reynolds, S., Wilson, C. & Creswell, C. 2017. Complete recovery from anxiety disorders following Cognitive Behavior Therapy in children and adolescents: A meta-analysis. Clinical Psychology Review, 52, 77-91.
Wozney, L., Mcgrath, P. J., Gehring, N. D., Bennett, K., Huguet, A., Hartling, L., Dyson, M. P., Soleimani, A. & Newton, A. S. 2018. eMental Healthcare Technologies for Anxiety and Depression in Childhood and Adolescence: Systematic Review of Studies Reporting Implementation Outcomes. JMIR Ment Health, 5, e48.