Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial

Jolstedt, Maral; Wahlund, Tove; Lenhard, Fabian; Ljótsson, Brjánn; Mataix‐Cols, David; Nord, Martina; Öst, Lars‐Göran; Högström, Jens; Serlachius, Eva; Vigerland, Sarah

doi:10.1016/s2352-4642(18)30275-x

Cited by 59 publications

(54 citation statements)

References 29 publications

(22 reference statements)

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“…This led to a decrease in BMI Z-scores of 0.14 (95% CI −0.28 to −0.003) at 6 months, with the trial powered to detect a decrease of 0.24 (no behavior change outcome was available). The third and fourth quite promising interventions were both internet-delivered CBT for children with anxiety disorders, both offering completely web-based modules for parents and children in conjunction with web-based therapist contact [ 60 , 63 , 64 ]. Both led to an improvement in anxiety as assessed by the clinician severity rating, equating to an estimated change of −077 (95% CI −1.15 to −0.40) at 3 months [ 60 ] and −1.16 (95% CI −1.55 to −0.77) at 10 weeks [ 63 ].…”

Section: Resultsmentioning

confidence: 99%

Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review

Brigden¹,

Anderson²,

Linney³

et al. 2020

J Med Internet Res

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Background The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years). Objective This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user’s experience of the digital intervention. Methods A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality. Results Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs) feedback and monitoring, shaping knowledge, repetition and substitution, and reward. Three papers included qualitative data on the user’s experience. We developed the following themes: parental involvement, connection with a health professional is important for engagement, technological affordances and barriers, and child-centered design. Conclusions Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (feedback and monitoring, shaping knowledge, repetition and substitution, and reward). This review suggests a model for improving the conceptualization and reporting of behavioral interventions involving children and parents.

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Section: Resultsmentioning

confidence: 99%

Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review

Brigden¹,

Anderson²,

Linney³

et al. 2020

J Med Internet Res

View full text Add to dashboard Cite

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“…Initial data were collected from 50 patients, of whom 33 (66%) were children participating in a study of ICBT for pediatric anxiety [24], and 17 (34%) were adolescents participating in a study of ICBT for pediatric OCD [25]. Main inclusion criteria were a primary diagnosis of separation anxiety disorder, social anxiety disorder, generalized anxiety disorder, panic disorder, or specific phobia according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and a clinical severity score above 3 on the Clinician Severity Rating (CSR) [26] or a primary diagnosis of OCD with a score of 16 or above on Children’s Yale Brown Compulsive Scale [27].…”

Section: Methodsmentioning

confidence: 99%

“…Clinicians scoring the iiPAS were the same licensed clinical psychologists (N=13) who provided online support as a part of the ICBT interventions. For more detailed information, see the original publications of the respective trials [24,25]. The regional ethical review board in Stockholm, Sweden, approved both studies.…”

Section: Methodsmentioning

confidence: 99%

“…The iiPAS was scored by the treating clinicians (N=21), of whom 20 were licensed psychologists and a licensed nurse. For more detailed information, see the original publications of each trial [24,29-32]. The regional ethical review board in Stockholm, Sweden, approved all trials.…”

Section: Methodsmentioning

confidence: 99%

“…The BiP TIC and BiP Anxiety trials had a randomized controlled design [24,29]. In BiP TIC, participants were randomized to either habit reversal training or exposure and response prevention.…”

Section: Methodsmentioning

confidence: 99%

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The Internet Intervention Patient Adherence Scale for Guided Internet-Delivered Behavioral Interventions: Development and Psychometric Evaluation

Lenhard¹,

Mitsell²,

Jolstedt³

et al. 2019

J Med Internet Res

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Background Patient adherence is defined as the extent to which a patient complies with medical or health advice. At present, there is a lack of reliable and valid measures specifically designed to measure adherence to internet-delivered behavioral interventions. Objective The objective of this study was to develop and psychometrically evaluate a novel measure of adherence to guided internet-delivered behavioral interventions. Methods In collaboration with experienced clinicians and researchers in the field, a 5-item, clinician-rated internet intervention Patient Adherence Scale (iiPAS) was developed. The initial scale was tested in a sample of children and adolescents (N=50) participating in internet-delivered cognitive behavioral therapy (ICBT) studies. A revised version of the iiPAS was then administered to a larger sample of children and adolescents (N=148) with various behavioral problems participating in ICBT trials. The scale was evaluated according to a classical test theory framework. Results The iiPAS demonstrated excellent internal consistency. Factor analyses revealed one underlying factor, explaining about 80% of the variance, suggesting that the scale captures a homogeneous adherence construct. The iiPAS was strongly associated with objective measures of patient activity in ICBT (number of logins, number of written characters, and completed modules). Furthermore, mid- and posttreatment ratings of the iiPAS were significantly correlated with treatment outcomes. By contrast, objective measures of patient activity in the Web-based platform did not correlate with treatment outcomes. Conclusions The iiPAS could be a useful tool to measure adherence in a broad range of internet-delivered behavioral interventions.

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Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents

Aspvall

Andersson

Melin

et al. 2021

JAMA

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In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.OBJECTIVE To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder. DESIGN, SETTING AND PARTICIPANTSA randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020. INTERVENTIONS Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment. MAIN OUTCOMES AND MEASURESThe primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS. RESULTS Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, −ϱ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).CONCLUSIONS AND RELEVANCE Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

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Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial

Abstract: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.

Cited by 59 publications

References 29 publications

Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review

Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review

The Internet Intervention Patient Adherence Scale for Guided Internet-Delivered Behavioral Interventions: Development and Psychometric Evaluation

Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents

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