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Chessell C, Halldorsson B, Walters S, Farrington A, Harvey K, Creswell C. Therapist guided, parent-led cognitive behavioural therapy (CBT) for pre-adolescent children with obsessive compulsive disorder (OCD): a non-concurrent multiple baseline case series. Behav Cogn Psychother 2024; 52:243-261. [PMID: 37840150 DOI: 10.1017/s1352465823000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) is an effective treatment for preadolescent children with obsessive compulsive disorder (OCD); however, there is a need to increase access to this treatment for affected children. AIMS This study is a preliminary evaluation of the efficacy and acceptability of a brief therapist-guided, parent-led CBT intervention for pre-adolescent children (5-12 years old) with OCD using a non-concurrent multiple baseline approach. METHOD Parents of 10 children with OCD were randomly allocated to no-treatment baselines of 3, 4 or 5 weeks before receiving six to eight individual treatment sessions with a Psychological Wellbeing Practitioner. Diagnostic measures were completed prior to the baseline, 1-week post-treatment, and at a 1-month follow-up, and parents completed weekly measures of children's OCD symptoms/impairment. RESULTS Seventy percent of children were 'responders' and/or 'remitters' on diagnostic measures at post-treatment, and 60% at the 1-month follow-up. At least 50% of children showed reliable improvements on parent-reported OCD symptoms/impairment from pre- to post-treatment, and from pre-treatment to 1-month follow-up. Crucially, the intervention was acceptable to parents. CONCLUSIONS Brief therapist-guided, parent-led CBT has the potential to be an effective, acceptable and accessible first-line treatment for pre-adolescent children with OCD, subject to the findings of further evaluations.
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Affiliation(s)
- Chloe Chessell
- School of Psychological and Clinical Language Sciences, University of Reading, UK
- Department of Experimental Psychology, University of Oxford, UK
- Department of Psychiatry, University of Oxford, UK
| | - Brynjar Halldorsson
- Department of Psychology, Reykjavik University, Iceland
- Landspitali, The National University Hospital of Iceland, Iceland
- Department of Experimental Psychology, University of Oxford, UK
- Department of Psychiatry, University of Oxford, UK
| | - Sasha Walters
- National Specialist CAMHS OCD, BDD, and Related Disorders Team, London, UK
- Oxford Psychological Intervention Centre, Oxford, UK
| | - Alice Farrington
- CAMHS Anxiety and Depression Pathway, Berkshire Healthcare NHS Foundation Trust, Reading, UK
| | - Kate Harvey
- School of Psychological and Clinical Language Sciences, University of Reading, UK
| | - Cathy Creswell
- Department of Experimental Psychology, University of Oxford, UK
- Department of Psychiatry, University of Oxford, UK
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Creswell C, Taylor L, Giles S, Howitt S, Radley L, Whitaker E, Brooks E, Knight F, Raymont V, Hill C, van Santen J, Williams N, Mort S, Harris V, Yu S, Pollard J, Violato M, Waite P, Yu LM. Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomised controlled trial. Lancet Psychiatry 2024; 11:193-209. [PMID: 38335987 DOI: 10.1016/s2215-0366(23)00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Anxiety problems are common in children, yet few affected children access evidence-based treatment. Digitally augmented psychological therapies bring potential to increase availability of effective help for children with mental health problems. This study aimed to establish whether therapist-supported, digitally augmented, parent-led cognitive behavioural therapy (CBT) could increase the efficiency of treatment without compromising clinical effectiveness and acceptability. METHODS We conducted a pragmatic, unblinded, two-arm, multisite, randomised controlled non-inferiority trial to evaluate the clinical effectiveness and cost-effectiveness of therapist-supported, parent-led CBT using the Online Support and Intervention (OSI) for child anxiety platform compared with treatment as usual for child (aged 5-12 years) anxiety problems in 34 Child and Adolescent Mental Health Services in England and Northern Ireland. We examined acceptability of OSI plus therapist support via qualitative interviews. Participants were randomly assigned (1:1) to OSI plus therapist support or treatment as usual, minimised by child age, gender, service type, and baseline child anxiety interference. Outcomes were assessed at week 14 and week 26 after randomisation. The primary clinical outcome was parent-reported interference caused by child anxiety at week 26 assessment, using the Child Anxiety Impact Scale-parent report (CAIS-P). The primary measure of health economic effect was quality-adjusted life-years (QALYs). Outcome analyses were conducted blind in the intention-to-treat (ITT) population with a standardised non-inferiority margin of 0·33 for clinical analyses. The trial was registered with ISRCTN, 12890382. FINDINGS Between Dec 5, 2020, and Aug 3, 2022, 706 families (706 children and their parents or carers) were referred to the study information. 444 families were enrolled. Parents reported 255 (58%) child participants' gender to be female, 184 (41%) male, three (<1%) other, and one (<1%) preferred not to report their child's gender. 400 (90%) children were White and the mean age was 9·20 years (SD 1·79). 85% of families for whom clinicians provided information in the treatment as usual group received CBT. OSI plus therapist support was non-inferior for parent-reported anxiety interference on the CAIS-P (SMD 0·01, 95% CI -0·15 to 0·17; p<0·0001) and all secondary outcomes. The mean difference in QALYs across trial arms approximated to zero, and OSI plus therapist support was associated with lower costs than treatment as usual. OSI plus therapist support was likely to be cost effective under certain scenarios, but uncertainty was high. OSI plus therapist support acceptability was good. No serious adverse events were reported. INTERPRETATION Digitally augmented intervention brought promising savings without compromising outcomes and as such presents a valuable tool for increasing access to psychological therapies and meeting the demand for treatment of child anxiety problems. FUNDING Department for Health and Social Care and United Kingdom Research and Innovation Research Grant, National Institute for Health and Care (NIHR) Research Policy Research Programme, Oxford and Thames Valley NIHR Applied Research Collaboration, Oxford Health NIHR Biomedical Research Centre.
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Affiliation(s)
- Cathy Creswell
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK.
| | - Lucy Taylor
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | - Sophie Giles
- Sussex Partnership NHS Foundation Trust, Worthing, UK
| | | | - Lucy Radley
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | - Emily Whitaker
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | - Emma Brooks
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Fauzia Knight
- Centre for Psychological Sciences, University of Westminster, London, UK
| | - Vanessa Raymont
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Claire Hill
- School of Psychology & Clinical Language Sciences, University of Reading, Reading, UK
| | - James van Santen
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Nicola Williams
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Sam Mort
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Victoria Harris
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Shuye Yu
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Pollard
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mara Violato
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Polly Waite
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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Creswell C, Chessell C, Halliday G. Parent-led cognitive behaviour therapy for child anxiety problems: overcoming challenges to increase access to effective treatment. Behav Cogn Psychother 2023; 51:512-532. [PMID: 36458498 DOI: 10.1017/s1352465822000546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Anxiety problems have a particularly early age of onset and are common among children. As we celebrate the anniversary of the BABCP, it is important to recognise the huge contribution that cognitive behavioural therapy (CBT) has made to the treatment of anxiety problems in children. CBT remains the only psychological intervention for child anxiety problems with a robust evidence base, but despite this, very few children with anxiety problems access CBT. Creative solutions are urgently needed to ensure that effective treatments can be delivered at scale. Here we focus on parent-led CBT as this offers a potential solution that is brief and can be delivered by clinicians without highly specialised training. Over the last decade there has been a substantial increase in randomised controlled trials evaluating this approach with consistent evidence of effectiveness. Nonetheless clinicians, and parents, often have concerns about trying the approach and can face challenges in its delivery. METHOD We draw on empirical evidence and our clinical experience to address some of these common concerns and challenges, with particular emphasis on the key principles of empowering parents and working with them to provide opportunities for new learning for their children. CONCLUSIONS We conclude by highlighting some important directions for future research and practice, including further evaluation of who does and does not currently benefit from the approach, determining how it should be adapted to optimise outcomes among groups that may not currently get maximum benefits and across cultures, and capitalising on recent technological developments to increase engagement and widen access.
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Affiliation(s)
- Cathy Creswell
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Chloe Chessell
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Gemma Halliday
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
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Green I, Reardon T, Button R, Williamson V, Halliday G, Hill C, Larkin M, Sniehotta FF, Ukoumunne OC, Ford T, Spence SH, Stallard P, Creswell C. Increasing access to evidence-based treatment for child anxiety problems: online parent-led CBT for children identified via schools. Child Adolesc Ment Health 2023; 28:42-51. [PMID: 36514819 PMCID: PMC10108299 DOI: 10.1111/camh.12612] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anxiety problems are extremely common and have an early age of onset. We previously found, in a study in England, that fewer than 3% of children with an anxiety disorder identified in the community had accessed an evidence-based treatment (Cognitive Behavioural Therapy; CBT). Key ways to increase access to CBT for primary school-aged children with anxiety problems include (a) proactive identification through screening in schools, (b) supporting parents and (c) the provision of brief, accessible interventions (and capitalising on technology to do this). METHOD We provided a brief, therapist guided treatment called Online Support and Intervention (OSI) to parents/carers of children identified, through school-based screening, as likely to have anxiety problems. Fifty out of 131 children from 17 Year 4 classes in schools in England screened positive for 'possible anxiety problems' and 42 (84%) of these (and 7 who did not) took up the offer of OSI. We applied quantitative and qualitative approaches to assess children's outcomes and families' experiences of this approach. RESULTS Inbuilt outcome monitoring indicated session on session improvements throughout the course of treatment, with substantial changes across measures by the final module (e.g. Child Outcome Rating Scale d = 0.84; Goal Based Outcomes d = 1.52). Parent engagement and satisfaction was high as indicated by quantitative and qualitative assessments, and intervention usage. CONCLUSIONS We provide promising preliminary evidence for the use of OSI as an early intervention for children identified as having anxiety problems through school-based screening.
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Affiliation(s)
- Iheoma Green
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Tessa Reardon
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | | | - Victoria Williamson
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Gemma Halliday
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
| | - Claire Hill
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Michael Larkin
- Department of Psychology, Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
| | - Falko F Sniehotta
- Department of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- NIHR Policy Research Unit Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
| | - Obioha C Ukoumunne
- NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Susan H Spence
- Australian Institute for Suicide Research and Prevention, and School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia
| | | | - Cathy Creswell
- Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK
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