Using stepped-care approaches within internet-based interventions for youth anxiety: Three case studies.

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. While 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

Structure of Anxiety Symptoms Among Children: A Confirmatory Factor-Analytic Study

This study examined the degree to which anxiety symptoms among children cluster into subtypes of anxiety problems consistent with Diagnostic and Statistical Manual of Mental Disorders (4th edition) classification of anxiety disorders. Two community samples of 698 children 8 - 12 years of age completed a questionnaire regarding the frequency with which they experienced a wide range of anxiety symptoms. Conformatory factor analysis of responses from Cohort 1 indicated that a model involving 6 discrete but correlated factors, reflecting the areas of panic - agoraphobia, social phobia, separation anxiety, obsessive-compulsive problems, generalized anxiety, and physical fears, provided an excellent fit of the data. The high level of covariance between latent factors was satisfactorily explained by a higher order model in which each 1st-order factor loaded on to a single 2nd-order factor. The findings were replicated with Cohort 2 and were equivalent across genders

A Measure of Anxiety Symptoms Among Children

The Spence Children's Anxiety Scale (SCAS) is a child self-report measure designed to evaluate symptoms relating to separation anxiety, social phobia, obsessive-compulsive disorder, panic-agoraphobia, generalized anxiety and fears of physical injury. The results of confirmatory and exploratory factor analyses supported six factors consistent with the hypothesized diagnostic categories. There was support also for a model in which the 1st-order factors loaded significantly on a single 2nd-order factor of anxiety in general. The internal consistency of the total score and subscales was high and 6 month test-retest reliability was acceptable. The SCAS correlated strongly with a frequently used child self-report measure of anxiety. Comparisons between clinically anxious and control children showed significant differences in total SCAS scores, with subscale scores reflecting the type of presenting anxiety disorder of the clinical samples

Associations between teacher-reported school climate and depressive symptoms in Australian adolescents : a 5-year longitudinal study.

Adolescent depression is serious and common. As adolescents spend approximately 15,000 h in school, this setting is a logical place to seek etiological factors. Research suggests there are negative associations between school climate and adolescent depressive symptoms. However, such studies typically use student reports of both climate and depressive symptoms; this is problematic because common method variance results when the same individual provides information on all variables, contributing to overestimations of associations between depressive symptoms and school climate. Therefore, the purpose of this study is to examine the association between teacher-reported school climate and adolescent-reported depressive symptoms. Thus, 2545 Australian high school students participated in this 5-year longitudinal study. Students completed a measure of depressive symptoms annually; their teachers (N = 882) completed a questionnaire to evaluate the quality of the school environment (i.e., safe/orderly and supportive relationships). Multi-group latent growth models revealed that more positive teacher-reported school climate was cross-sectionally associated with fewer student-reported depressive symptoms in both boys and girls, although this association was significantly stronger for girls. Longitudinally, positive school climate was associated with lower depressive symptoms but a higher rate of change of symptoms for both boys and girls. The overall findings are consistent with previous findings with student-reported school climate. However, the gender difference and the directionality of the longitudinal association between school climate and depressive symptoms over time demonstrate that additional studies of mechanisms by which school climate is connected to adolescents’ depressive symptoms are needed

Associations between teacher-reported school climate and depressive symptoms in Australian adolescents : a 5-year longitudinal study.

Adolescent depression is serious and common. As adolescents spend approximately 15,000 h in school, this setting is a logical place to seek etiological factors. Research suggests there are negative associations between school climate and adolescent depressive symptoms. However, such studies typically use student reports of both climate and depressive symptoms; this is problematic because common method variance results when the same individual provides information on all variables, contributing to overestimations of associations between depressive symptoms and school climate. Therefore, the purpose of this study is to examine the association between teacher-reported school climate and adolescent-reported depressive symptoms. Thus, 2545 Australian high school students participated in this 5-year longitudinal study. Students completed a measure of depressive symptoms annually; their teachers (N = 882) completed a questionnaire to evaluate the quality of the school environment (i.e., safe/orderly and supportive relationships). Multi-group latent growth models revealed that more positive teacher-reported school climate was cross-sectionally associated with fewer student-reported depressive symptoms in both boys and girls, although this association was significantly stronger for girls. Longitudinally, positive school climate was associated with lower depressive symptoms but a higher rate of change of symptoms for both boys and girls. The overall findings are consistent with previous findings with student-reported school climate. However, the gender difference and the directionality of the longitudinal association between school climate and depressive symptoms over time demonstrate that additional studies of mechanisms by which school climate is connected to adolescents’ depressive symptoms are needed

Internet‐delivered cognitive behavior therapy with minimal therapist support for anxious children and adolescents: predictors of response

Background: In general, Internet-delivered cognitive behavior therapy (iCBT) produces significant reductions in child and adolescent anxiety, but a proportion of participants continue to show clinical levels of anxiety after treatment. It is important to identify demographic, clinical, and family factors that predict who is most likely to benefit from iCBT in order to better tailor treatment to individual needs. Methods: Participants were 175 young people (7–18 years) with an anxiety disorder, and at least one of their parents, who completed an iCBT intervention with minimal therapist support. Multilevel modeling (MLM) examined predictors of response to iCBT as measured by the slope for changes in the primary outcome measures of child- and parent-reported anxiety scores, from pretreatment, to 12-weeks, 6-month, and 12-month follow-ups, controlling for pretreatment total clinician severity ratings of all anxiety diagnoses. Results: Child age, gender, father age, parental education, parental mental health, parenting style, and family adaptability and cohesion did not significantly predict changes in anxiety in the multivariate analyses. For child-reported anxiety, greater reductions were predicted by a separation anxiety disorder diagnosis (SEP) and elevated depression, with lower reductions predicted by poor couple relationship quality. For parent-reported child anxiety, greater reductions were predicted by higher pretreatment total CSRs, SEP, and lower family income, with lower reductions for children of older mothers. Irrespective of these predictors of change, children in general showed reductions in anxiety to within the normal range. Conclusions: Overall, children responded well to iCBT irrespective of the demographic, clinical, and family factors examined here. Poor couple relationship quality and older mother age were risk factors for less positive response to iCBT in terms of reductions in anxiety symptoms although still to within the normal range

Large-scale dissemination of internet-based cognitive behavioral therapy for youth anxiety: feasibility and acceptability study

Background: Internet-based cognitive behavioral therapy (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but it has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs could be a promising first-step, low-intensity intervention that can be easily accessed by young people. Objective: The objective of our study was to examine the feasibility and acceptability of a publicly available online, self-help iCBT program (BRAVE Self-Help) through exploration of program adherence, satisfaction, and changes in anxiety. Methods: This study was an open trial involving the analysis of data collected from 4425 children and adolescents aged 7-17 years who presented with elevated anxiety at registration (baseline) for the iCBT program that was delivered through an open-access portal with no professional support. We assessed the program satisfaction via a satisfaction scale and measured adherence via the number of completed sessions. In addition, anxiety severity was assessed via scores on the Children’s Anxiety Scale, 8-item (CAS-8) at four time points: baseline, Session 4, Session 7, and Session 10. Results: Participants reported moderate satisfaction with the program and 30% completed three or more sessions. Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed six or more sessions, there was an average 4-point improvement in CAS-8 scores (Cohen d=0.87, children; Cohen d=0.81, adolescents), indicating a moderate to large effect size. Among participants who completed nine sessions, 57.7% (94/163) achieved recovery into nonelevated levels of anxiety and 54.6% (89/163) achieved statistically reliable reductions in anxiety. Conclusions: Participant feedback was positive, and the program was acceptable to most young people. Furthermore, significant and meaningful reductions in anxiety symptoms were achieved by many children and adolescents participating in this completely open-access and self-directed iCBT program. Our results suggest that online self-help CBT may offer a feasible and acceptable first step for service delivery to children and adolescents with anxiety

Primary school-based screening for childhood mental health problems and intervention delivery: a qualitative study of parents in challenging circumstances

Few children with mental health problems access evidence-based interventions. Primary schools may be an ideal setting to improve access to treatment through screening and intervention programmes, but some families’ circumstances and experiences may increase barriers to benefiting from this approach. Interviews were carried out with parents of children living in potentially challenging circumstances, including foster and military-connected families. We aimed to explore parent perceptions of a school-based screening/intervention programme and potential barriers to uptake. Parents described that due to their past experiences, that they might not trust or engage with a school-based screening/intervention. Nonetheless, parents considered that the delivery of a sensitive school screening/intervention programme might provide an opportunity for schools to strengthen their relationship with families. These findings highlight the need for future school-based screening/intervention programmes for child mental health to consider the needs of families of children from varied circumstances, and ensure steps are taken to promote trust

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial

Background: Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed). Objective: This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help). Methods: This study’s participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session. Results: The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements. Conclusions: These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary