Reaching Young People in Urban and Rural Communities with Mental Health and Wellbeing Support Within a Youth Sports Development Program: Integrating In-Person and Remote Modes of Service Delivery

Embedding mental health and wellbeing programs within youth sports development programs can help provide more young people with mental health support. However, delivering such programs in multiple locations across metropolitan, regional, and rural areas requires novel solutions to overcome geographic and logistical barriers. We examined the delivery of an integrated system delivered within an Australian junior rugby league program. The program included online assessment and feedback about youth mental health, as well as connection with evidence-informed resources and referral sources via parent telephone and email support. There were four methods of delivering player workshops during training sessions: (a) In-person Delivery Only, (b) In-person + Remote Real-time (video-conferenced), (c) In-person + Remote Prerecorded (video-recorded), and (d) Remote Delivery Only (video-conferenced and/or video-recorded). In-person delivered player workshops were facilitated by local rugby league personnel. Remote delivered workshops were facilitated by psychologists from the mental health research team. Participants were 671 boys (12-15 years; M age = 13.35; SD = 0.35) in 21 metropolitan, regional and rural locations. Regardless of delivery condition, players with elevated anxiety, depression and behavioural problems reported significant declines in symptoms from pre- to post-program, and those within healthy ranges did not change from pre- to post-program. Player workshop enjoyment ratings were higher in the In-person + Remote Real-time condition and the Remote Delivery Only condition than the In-person Delivery Only condition. However, non-completion of the post-program assessment across all conditions was higher than in prior studies and a comparison group of players who did not complete the program was not included. Mental health benefits may be observed across in-person and remote modes of delivering mental health workshops within youth sports programs. However, the involvement of mental health personnel, whether in-person or remotely, and mixed delivery modes, may be important for young people's retention and satisfaction.

Motivational processes contributing to disturbances in women's body image and eating

Reinforcement Sensitivity Theory (RST) provides a neurobiological personality framework for understanding approach and avoidance behavioural patterns. Recent research suggests an association between RST personality traits (reward interest and behavioural inhibition system [BIS]) and women's body image and eating behaviours. The current study aimed to extend this research by testing for indirect relationships between reward interest and BIS and eating disorder symptoms, as mediated through thin ideal internalisation. Adult female participants (N = 354, M = 22.06 years of age, SD = 6.78) completed self-report measures of reward interest, BIS, thin ideal internalisation, and eating disorder symptoms (i.e., restraint, eating concerns, weight and shape concerns). Indirect relationships were tested using bootstrapped mediation analyses. Results showed thin ideal internalisation mediated the pathways between the BIS and restraint, eating concern, and weight and shape concerns. Reward interest was not associated with thin ideal internalisation, or with eating disorder symptoms. Although the application of RST to women's body image is an emerging research area, these novel findings suggest BIS trait sensitivity may increase women's risk of body image concerns and restricted eating, via increased levels of thin ideal internalisation. Overall, these findings provide preliminary support for inclusion of individual differences in BIS sensitivity in risk factor models of body image and eating disturbances. Future research should aim to replicate these findings in more diverse samples, using longitudinal designs.

Stepped-care versus therapist-guided, internet-based cognitive behaviour therapy for childhood and adolescent anxiety: A non-inferiority trial

Objective

This preregistered randomized trial examined whether a stepped-care approach to internet-delivered cognitive behaviour therapy (ICBT-SC) is non-inferior to therapist-guided ICBT (ICBT-TG) for child and adolescent anxiety.

Method

Participants were 137 Australians, aged 8-17 years (56 male), with a primary anxiety disorder. This randomized, non-inferiority trial compared ICBT-SC to an evidence-based, ICBT-TG program with assessments conducted at baseline, 12 weeks and 9-months after treatment commencement. All ICBT-SC participants completed the first 5 online sessions without therapist guidance. If they responded to treatment in the first 5 sessions (defined as reductions of anxiety symptoms into non-clinical range), they continued without therapist guidance for the final 5 sessions. If they did not respond to treatment in the first 5 sessions, the final five sessions were supplemented with therapist-guidance (through email). All ICBT-TG participants received therapist guidance (email) after each session, for all 10 sessions. Measures included clinical diagnostic interview (severity rating as primary outcome), as well as parent and child reported anxiety and anxiety-related interference (secondary outcomes).

Results

ICBT-SC was found to be non-inferior to ICBT-TG on primary and secondary outcomes, according to clinician, parent and young person report at 12-weeks and 9-months. Treatment satisfaction was moderate to high for both conditions. Significant clinical benefits were evident for participants in both treatments. Of participants who remained in the study, 77 % (50.7 % ITT) of ICBT-SC and 77 % (57.1 % ITT) of ICBT-TG were free of their primary anxiety diagnosis by 9-month follow-up, with no differences between conditions.

Conclusion

A stepped-care ICBT approach for clinically anxious children and adolescents may offer an acceptable treatment model that can increase access to evidence-based treatment.

Short Research Article: Changes in life functioning in a self-help, online program for child and adolescent anxiety

BACKGROUND

Anxiety-related functional impairment, as reflected by life interference, is a lesser explored but highly relevant treatment outcome, and it is crucial that it be included and examined in the evaluation of treatment outcomes of internet-delivered Cognitive Behavioural Therapy (iCBT).

METHODS

This single group, pre-post study examined changes in life interference and anxiety symptoms in a sample of children (n = 1198; mean age 9.66 years) and adolescents (n = 721; mean age 13.66 years) participating in the BRAVE Self-Help program in Australia.

RESULTS

Results demonstrated that both children and adolescents showed improvements in anxiety symptoms, with effect sizes ranging from ηp 2  = .194-.318. Reductions in life interference were evident for children (ηp 2  = .008-.044), particularly later in the programme, but adolescents did not show such effects. Adolescents in the low completer group (completing 3-5 sessions) showed increases in at-home interference (ηp 2  = .038).

CONCLUSIONS

Adolescents in particular may require more sessions before entrenched life interference, such as that resulting from avoidance behaviours, can be overcome.

Helping Clinicians Conceptualise Behavioural Insomnia in Children: Development of the Manifestations and Vulnerabilities of Behavioural Insomnia in Childhood Scale (MAVBICS)

This paper outlines the development and psychometric evaluation of the Manifestations and Vulnerabilities of Behavioural Insomnia in Childhood Scale (MAVBICS), an instrument intended to assess the manifestations of, and factors underpinning, child behavioural insomnia. The MAVBICS comprises two sections: a more general sleep and bedtime information section (Section 1), and a psychometric measure of six theoretically derived factors that underlie, contribute to, and are manifestations of, child sleep problems (Section 2), that is the focus of this research. Study 1 comprised an exploratory factor analysis of Section 2 items (EFA; n = 328 parents of children aged 3-12 years), with a final 25 items found to load highly onto 6 factors; Sleep Maintenance Problems (4 items, α = 0.88), Co-Sleeping Behaviours (4 items, α = 0.93), Bedtime Routines (5 items, α = 0.82), Bedtime Resistance (5 items, α = 0.88), Bedtime Worries (3 items, α = 0.85) and Bedtime Fears (4 items, α = 0.86). Study 2 comprised a confirmatory factor analysis (CFA) of Section 2 items and tests of convergent validity (n = 313), with results confirming the factor structure and providing evidence for convergent validity through correlations in expected directions between MAVBICS scores and other sleep, anxiety and behaviour measures. Study 3 tested the test-retest reliability of Section 2 items (n = 53), and found support for the temporal stability of the MAVBICS over a 2-week period. Overall, the results provide strong preliminary evidence for the validity of the MAVBICS total score and its subscales, although the Bedtime Routines subscale may be less useful.

Thin Ideal Internalization Assessment (THIINA): Development and Psychometric Validation of a New Measure of Female Body Image

Thin ideal internalization is widely implicated in women's body image and eating disturbances. A recently proposed multidimensional operationalization of internalization suggests the brevity and construct validity of existing questionnaires may limit the assessment of thin ideal internalization. Therefore, this research aimed to develop a new questionnaire (i.e., Thin Ideal Internalization Assessment; THIINA) to comprehensively assess thin ideal internalization. In Study 1, 301 female participants were administered the THIINA. Exploratory factor analyses revealed the 17-item THIINA had a stable 3-factor structure reflecting thin idealization, thin overvaluation, and thin behavioral drive. In Study 2, 337 female participants were administered the THIINA and validation measures. Confirmatory factor analysis confirmed stability of the 3-factor structure and findings supported convergent, discriminant, and incremental validity of the THIINA. Support for temporal stability was found within a sub-sample of participants (n = 132). The THIINA demonstrated strong psychometric properties, a stable three-factor structure representing theoretically-driven domains, and support for the creation of a composite score representing overall thin ideal internalization. These findings suggest the multidimensional operationalization and measurement of thin ideal internalization could improve theoretical and clinical understanding of the impact of thin ideal internalization on women's body image and eating.

Treating sleep problems in young children: A randomised controlled trial of a group-based, parent-focused behavioural sleep intervention

This study tested the efficacy of a 5 × 1.5 h/session, group-based, parent-focused, behavioural intervention (BI) targeting sleep problems in preschool children. Parents were randomised to either the BI (N = 62) or care as usual (CAU; N = 66) conditions. Outcomes included sleep, anxiety, behavioural problems, internalising and externalising symptoms, transition to school and academic achievement. Assessments were conducted at pre- and post-BI intervention (in the year prior to formal schooling), and then at follow-ups 1 and 2 in the first year of formal schooling. Relative to the CAU, the BI condition demonstrated significantly greater improvements in sleep, anxiety, behaviour problems and internalising and externalising symptoms from pre-to post-intervention. Improvements in sleep, anxiety, and internalising symptoms were maintained, while behaviour and externalising symptoms were further improved upon at school follow-up 2. For the BI group, improvements in sleep at post-intervention were found to mediate improvements in anxiety, internalising, and externalising symptoms, but not behaviour problems, at school follow-ups 1 and 2. There were no significant effects of condition on school transition or academic outcome measures. The results suggest that the BI is effective for sleep, anxiety, behaviour, internalising and externalising symptoms, but not for school transition or academic outcomes. ANZCTR NUMBER: ACTRN12618001161213.

Mental health symptoms in children and adolescents during COVID-19 in Australia

OBJECTIVE

COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment.

METHODS

An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured.

RESULTS

Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms.

CONCLUSION

Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities.

Feasibility of an Intensive, Disorder-Specific, Group-Based Cognitive Behavioural Therapy Intervention for Adolescents with Social Anxiety Disorder

This study examined the preliminary acceptability and efficacy of an intensive, group-based, disorder-specific cognitive behavioural therapy (CBT) intervention for adolescents with social anxiety disorder (SAD). Fourteen Australian adolescents with SAD (78.6% female, M age = 13.93 years) and their parents completed the program plus measures of treatment satisfaction, and provided feedback. Clinical interviews and surveys were administered pre-treatment, post-treatment, and at 6-month follow-up to determine diagnostic status and assess related variables. Post-treatment satisfaction scores were very high for adolescents and parents. Post-treatment, 32.3% of participants no longer met criteria for SAD diagnosis, increasing to 42.9% at follow-up. Participants showed sizeable reductions in comorbid diagnoses, significant improvements in global functioning, social anxiety symptoms, and internalising symptoms from pre- to post-treatment (maintained at follow-up), and significant improvements in social skills and social competence from pre-treatment to follow-up. This study supports the use of an intensive CBT program for adolescents with SAD.

FAST CBT for pediatric OCD: A multiple-baseline controlled pilot trial of parent training in exposure and response prevention delivered via telehealth

Objective

The current study utilized a single case series, non-concurrent multiple baseline design to examine the efficacy of training parents via telehealth videoconferencing in exposure and response prevention (ERP) for home delivery of the treatment for their children and adolescents with obsessive compulsive disorder (OCD).

Method

There were nine participants aged 8 to 14  years who had received a primary diagnosis of OCD. The design involved a series of AB replications, whereby following pre-treatment assessments participants were randomly assigned to either a 2-week (n = 4) or 3-week (n = 5) baseline condition with weekly monitoring of their child's OCD symptoms. Following baseline, parents participated four weekly telehealth parent-training modules in delivering FAST (Families Accessing Skills Training) cognitive behavior therapy (CBT) with ERP (CBT-ERP) to children with OCD via videoconferencing with the clinician. Primary outcome measures were OCD symptom severity, diagnostic severity, and global functioning, which were assessed post-treatment and at 2 month follow-up.

Results

The stability of the baseline period from pre-treatment to week 2 (for the 2-week condition) or to week 3 (for the 3-week condition) was established as there were no significant differences across baseline scores for parent target obsessions or parent target compulsions ratings. Significant improvements on the primary outcomes of clinician assessed symptom severity, diagnostic ratings, and global functioning were observed from baseline to post-treatment, and continued to 2 months follow-up.

Conclusion

These data suggest that brief, parent training in FAST CBT-ERP via telehealth provides an overall effective intervention that is likely to be of most benefit to children and youth who are mild to moderate in severity.

Looking at me, looking at you: The mediating roles of body surveillance and social comparison in the relationship between fit ideal internalisation and body dissatisfaction

Understanding the mechanisms through which internalisation of societal body standards lead to negative outcomes for women is important to inform prevention and treatment strategies targeting female body image issues and problematic eating and exercise behaviours. This study investigated the mediating roles of body surveillance and social comparison on the relationship between fit-ideal internalisation and a range of negative eating and body image related outcomes. Participants were 448 females, aged 16-25 years who completed self-report measures of fit-ideal internalisation, body surveillance, social comparison, body dissatisfaction, dieting, bulimic behaviours and compulsive exercise. Consistent with hypotheses, the results of parallel mediation analyses suggested that both body surveillance and social comparison mediated the relationship between fit-ideal internalisation and body dissatisfaction, dieting and bulimic behaviours. However, only social comparison was found to mediate the relationship between fit-ideal internalisation and compulsive exercise. The results suggest both body surveillance and social comparison are mechanisms by which fit internalisation detriments women's body image, making them potentially useful treatment targets for future research.

Examining the Process of Implementing a Three-Step Mental Health and Wellbeing System of Care for Children and Adolescents Across Multiple Community Settings

Mental health problems affect large numbers of young people. Integrated systems are required that can be applied in diverse settings to reach youth 'where they are'. We evaluated the process of implementing a three-step youth mental health and wellbeing system in diverse community settings according to three implementation outcomes: feasibility, penetration and acceptability. The study describes 49 applications of the 'Life-Fit-Learning system' designed to assess the mental health and wellbeing of youth (Assess step), provide feedback on assessment results (Reflect step), and connect them to resources and services proportionate to their needs (Connect step). Within a participatory research approach, 3798 administrations were conducted with youth between 9 and 18 years and 90 administrations were conducted with adults. Implementation was based on the four phases of the Quality Implementation Framework and was staged to integrate stakeholder and consumer feedback and experience gained from focus groups and two pilot phases before full implementation. Feasibility ratings of successful implementation ranged from 86.7 to 96.4% across applications and settings. High penetration rates were achieved. The Life-Fit-Learning system successfully reached 91.9% to 96% of youth with the Assess and Reflect steps and low intensity Connect step resources. Of those, 14.7% to 23% were identified at-risk for mental health problems and 93% to 97% of those at-risk youth additionally received Connect step co-delivered group-based programs (moderate intensity care) and/or individual treatment (high intensity care). Youth and parents reported high satisfaction across all steps and delivery modes. With strong collaboration, an integrated model of care can be delivered feasibly, effectively and satisfactorily to reach large numbers of young people across settings.

Body Image Projection Bias in Heterosexual Romantic Relationships: A Dyadic Investigation

Guided by projection bias perspectives, this article sought to advance understanding of the associations between body image and relationship and sexual satisfaction within heterosexual romantic relationships. Across two studies, both members of heterosexual dating and/or married couples reported on their body image, perceptions of partner's attraction to the self, own attraction toward the partner, and relationship satisfaction. Study 2 also incorporated measures of participants' body mass index (BMI) and sexual satisfaction. Across both studies, women with poorer body image perceived their partner to be less attracted to them (irrespective of their partner's actual attraction to them, or how attracted they were to their partner), which in turn was associated with lower relationship and sexual satisfaction. For men, attraction to their partner was consistently associated with their own relationship satisfaction. Results demonstrate that projection biases are a possible mechanism through which body image is associated with romantic relationship and sexual satisfaction, and hint at the particular relevance of appearance-related projection biases for women's relationship and sexual satisfaction.

Does culture moderate the relationship between body dissatisfaction and quality of life? A comparative study of Australian and Malaysian emerging adults

Investigating moderating effects of culture between body dissatisfaction (BD) and quality of life (QoL) is paramount, as BD affects psychosocial functioning. Participants include 866 females (18–25) years old from Australia (n = 464) M (20.88) SD (3.38) and Malaysia (n = 402) M (20.63) SD (2.05). Higher levels of BD predicted lower levels of QoL across all four domains. BD had the strongest effect on psychological QoL for both cultures. Culture moderated the relationship between BD and: (i) physical QoL and (ii) environmental QoL. The adverse impact of BD on all domains of QoL, highlights the importance of BD as a public health problem.

Virtual Reality One-Session Treatment of Child-Specific Phobia of Dogs: A Controlled, Multiple Baseline Case Series

Specific phobia (SP) typically onsets in childhood and frequently predicts other mental health disorders later in life. Fortunately, childhood SP can be effectively treated with cognitive behavior therapy (CBT), including the exposure-based one-session treatment (OST) approach. Despite empirical support for CBT and OST, clinicians, for various reasons, frequently fail to implement exposure-based therapy in routine clinical practice, including perceived difficulties in implementing exposure. Virtual reality (VR) exposure therapy may overcome some of these challenges and provides an alternative modality of therapy. This preliminary study examined the efficacy of VR OST for 8 children with a SP of dogs (aged 8-12 years) (M = age 10.25; SD = 2.11) using a multiple-baseline controlled case series. Following a stable baseline period of either 2, 3, or 4 weeks, it was expected that specific phobia severity would significantly decline after VR OST and remain improved over the 3-week maintenance phase. Assessments were conducted posttreatment and at 1-month follow up (study end-point). It was found that phobia symptoms remained relatively stable across the baselines, with significant reductions from pretreatment to posttreatment and to follow-up on clinician severity ratings (pre- to post- g = 1.12; pre- to follow-up g = 2.40), target symptom ratings (g = 1.14; 1.29), and behavioral avoidance (g = -1.27; -1.96). The treatment was also associated with clinically significant outcomes, whereby at one-month follow up, 75% of children were considered "recovered" and 88% completed the BAT (interacted with their feared stimuli). This study provides support for the effectiveness of VR OST.

Tackling Mental Health in Youth Sporting Programs: A Pilot Study of a Holistic Program

Linking mental health services to organised sport offers an avenue to identify and improve mental health among adolescents. In this study, we investigated the efficacy, acceptability and feasibility of an integrated mental health system embedded within a junior sports development program. A three-step integrated mental health program for 12- to 15-year-old rugby league players (N = 74) was delivered in urban (n = 44) and rural (n = 33) areas. Specifically, this system (a) assessed participant mental health on primary outcome measures of anxiety, depression, and anger/conduct problems (and secondary outcome measures of personal attributes and relationships), (b) provided feedback to participants, parents and program coordinators, and (c) connected participants and parents to a multi-component intervention including online resources, a group-based workshop program (4 × 30-min sessions), and tailored individual-level follow-up and referral to further care for participants at high risk of mental health problems. From pre- to post-program, boys' anxiety symptoms declined significantly (with only a trend-level reduction in depression), and there were significant improvements in grit (for urban boys only), efficacy to manage negative emotions, and prosocial behaviour. In addition, when boys reported symptoms associated with high risk for mental health problems, providing parents with feedback enhanced boys' access to care and was associated with significant declines in anxiety symptoms. The program was generally acceptable and feasible, with very high retention in the youth sports development program. Overall, early findings support further deployment and evaluation of integrated mental health systems embedded within sporting contexts to address mental health problems among adolescent boys.

Strong is the New Skinny, but is it Ideal?: A Test of the Tripartite Influence Model using a new Measure of Fit-Ideal Internalisation

Although the thin body ideal has been the epitome of western female beauty for decades, the more recent fit body ideal is becoming arguably more popular. This study aimed to test two versions of the tripartite influence model (TIM; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999): one that included thin-ideal internalisation, and one that included fit-ideal internalisation, using path analysis. Participants were 558 Australian women aged 16-50 years (M = 22.06, SD = 7.41). All of the hypothesised paths were significant for both the thin- and fit-ideal internalisation models. The final models for both thin- and fit-ideal internalisation included extra, non-hypothesised paths from media to body dissatisfaction, and from social comparison to dieting, bulimic symptoms, and compulsive exercise. The two models differed in that the final model for thin-ideal internalisation included direct paths from thin-ideal internalisation to dieting and bulimic symptoms. The final model for fit-ideal internalisation, however, included a direct path from fit-ideal internalisation to compulsive exercise. It was concluded that, in contrast to the widely held perception that the fit ideal is a 'healthier' alternative to the thin ideal, fit ideal internalisation may be detrimental to female body satisfaction, disordered eating, and compulsive exercise.

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.

Social support as a predictor of treatment adherence and response in an open-access, self-help, internet-delivered cognitive behavior therapy program for child and adolescent anxiety

BACKGROUND

Although self-help, internet-based cognitive behaviour therapy (ICBT) can produce significant reductions in anxiety for many young people, a sizable proportion show low program adherence and continue to show anxiety problems after treatment. It is important that we identify factors that predict those most likely to complete program sessions and benefit from self-help ICBT so that we can better match interventions to individual needs, and inform program design and development.

OBJECTIVE

This study examined the role of social support in predicting treatment adherence and outcome among youth enrolled in an open-access, internet-delivered, CBT intervention targeting anxiety.

METHODS

Participants were 3684 young people (aged 7 to 17 years) who reported elevated levels of anxiety symptoms when registering for the program. Treatment adherence was assessed as number of treatment sessions completed. Treatment response was evaluated as change in self-reported anxiety symptoms. Youth-reported social support (from friends, family and a special person) at pre-treatment was examined as a hypothesized predictor of adherence and outcome after controlling for baseline anxiety, gender, and age, with age being examined as a moderator.

RESULTS

Linear regression analyses showed that participants with greater social support, from all sources, tended to show greater program adherence, although the proportion of explained variance was small. Age moderated the effect of family support upon adherence, such that greater family support was associated with greater number of sessions completed only for older youth. Greater family and total support were associated with greater reductions in anxiety, irrespective of participant age, but again the percent of variance explained was small. Younger participants were more likely to complete more sessions and to show greater reductions in anxiety. Those with higher pre-treatment anxiety tended to complete fewer sessions but demonstrated greater reductions in anxiety.

CONCLUSIONS

The findings highlight the need to consider ways to enhance treatment adherence and outcome of those engaging in self-help ICBT for youth anxiety problems, particularly when social support is low.

Behavioral Sleep-Related Problems in Clinically Anxious Children: A Parent-Report Diary Study

Anxiety disorders and behavioral sleep-related problems (SRPs) frequently co-occur during childhood. However, few studies have used the recommended method of a sleep-diary. The present study examined parental perceptions of behavioral SRPs in anxious compared to non-anxious children using a sleep-diary. Parents of 22 clinically anxious children and 29 healthy controls (aged 6-13 years) completed a 7-day sleep-diary of their child's behavioral SRPs. Compared to non-anxious peers, anxious children were rated by parents as more often (a) having a negative mood before bed, (b) delaying bed, (c) requiring parental assistance during the night, especially on weeknights, (d) having difficulty waking on their own the next morning, (e) falling back to sleep after morning waking, and (f) waking in a negative mood. There were no significant group differences in sleep onset latency or sleep duration, and behavioral SRPs of anxious children did not negatively affect their functioning or that of their parents the next day based on parent report. Parents of anxious children are more likely to perceive their children as engaging in behavioral SRPs compared to parents of non-anxious children.

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.

Ambulatory Assessment of Adolescent Coping: It's a Complicated Process

Scholars have long-called for researchers to treat coping as a process that is measured over an arc of time. Ambulatory assessment (AA) offers an appealing tool for capturing the dynamic process of adolescent coping. However, challenges in capturing the coping process are not altogether circumvented with AA designs. We conducted a scoping review of the AA literature on adolescent coping and draw from 60 studies to provide an overview of the field. We provide critiques of different AA approaches and highlight benefits and costs associated with various types of measurement within AA. We also speak to considerations of participant burden and compliance. We conclude with recommendations for developmental scholars seeking to deploy AA to capture this quintessential process among adolescents.

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.

D-cycloserine-augmented one-session treatment of specific phobias in children and adolescents

BACKGROUND

D-Cycloserine has potential to enhance exposure therapy outcomes. The current study presents a preliminary randomized, placebo-controlled double-blind pilot trial of DCS-augmented one-session treatment (OST) for youth (7-14 years) with specific phobia. A secondary aim of this pilot study was to explore the effects of youth age and within-session fear reduction as potential moderators of DCS outcomes in order to generate hypotheses for a larger trial. It was hypothesized that DCS would be associated with greater improvements than placebo, that children (7-10 years) would have greater benefits than adolescents (11-14 years), and that DCS effects would be stronger for participants with the greater within-session fear reduction during the OST.

METHODS

Thirty-five children and adolescents were randomized to either OST combined with DCS (n = 17), or OST combined with placebo (PBO; n = 18) and assessed at 1 week, 1 month, and 3 month following treatment.

RESULTS

There were no significant pre- to post-treatment or follow-up benefits of DCS relative to placebo. Secondary analyses of age indicated that relative to PBO, DCS was associated with greater improvements for children (but not adolescents) on measures of severity at 1-month follow-up. Children in the DCS condition also showed significantly greater improvement to 1 month on global functioning relative to other groups. Conversely, adolescents had significant post-treatment benefits in the PBO condition on symptom severity measures relative to DCS, and adolescents in the DCS condition had significantly poorer functioning at 3 months relative to all other groups. Finally, there was a trend for within-session fear reduction to be associated with moderating effects of DCS, whereby greater reduction in fear was associated with greater functioning at one-month follow-up for children who received DCS, relative to PBO.

LIMITATIONS

The study sample was small and therefore conclusions are tentative and require replication.

CONCLUSIONS

Age and within-session fear reduction may be important moderators of DCS-augmented one-session exposure therapy, which requires testing in a fully powered randomized controlled trial.

What's the Worry with Social Anxiety? Comparing Cognitive Processes in Children with Generalized Anxiety Disorder and Social Anxiety Disorder

Social anxiety disorder (SAD) in children is often comorbid with generalized anxiety disorder (GAD). We investigated whether worry, intolerance of uncertainty, beliefs about worry, negative problem orientation and cognitive avoidance, that are typically associated with GAD, are present in children with SAD. Participants included 60 children (8-12 years), matched on age and gender. Groups included children: with primary GAD and without SAD (GAD); with primary SAD and without GAD (SAD); and without an anxiety disorder (NAD). GAD and SAD groups scored significantly higher than the NAD group on worry, intolerance of uncertainty, negative beliefs about worry and negative problem orientation, however, they did not score differently from each other. Only the GAD group scored significantly higher than the NAD group on cognitive avoidance. These findings further understanding of the structure of SAD and suggest that the high comorbidity between SAD and GAD may be due to similar underlying processes within the disorders.

Can we improve parent attitudes and intentions to access computer-based therapies for their children and adolescents?

BACKGROUND

As gatekeepers, parents can improve the uptake of mental health services among youth. This article asked whether providing parents with a presentation on computer-based therapies is a feasible strategy to improve their knowledge, attitudes and uptake intentions.

METHOD

Parents completed a survey before, and immediately after, viewing a presentation on computer-based therapies or an active control.

RESULTS

Parents who viewed the computer-based presentation reported significantly greater improvements in knowledge, perceived helpfulness, perceived benefits and intentions to access computer-based therapies; and a significantly greater reduction in perceived problems, compared to active controls.

CONCLUSIONS

Information- and demonstration-based presentations are a feasible method for improving attitudes towards computer-based therapies for youth among parents in the community.

Efficacy of an internet-based CBT program for children with comorbid High Functioning Autism Spectrum Disorder and anxiety: A randomised controlled trial

BACKGROUND

All trials conducted to date on BRAVE-ONLINE for youth anxiety disorders have excluded children with High Functioning Autism Spectrum Disorder (HFASD) and therefore it is unknown whether these programs might be beneficial to HFASD children. The aim of this study was to evaluate the efficacy of BRAVE-ONLINE in HFASD children with an anxiety disorder.

METHODS

Forty-two HFASD children, aged 8-12 years, with an anxiety disorder, and their parents, were randomly assigned to either the BRAVE-ONLINE condition (NET) or a waitlist control (WLC). Diagnostic interviews and parent/child questionnaires were completed at pre-treatment, post-treatment and 3-month follow-up.

RESULTS

At post- assessment, compared to children in the WLC condition, children in the NET condition demonstrated a significantly greater reduction in number of anxiety diagnoses, clinical severity of diagnosis, and self and parent reported anxiety symptoms, as well as significantly greater increases in overall functioning. However, loss of primary diagnosis in this sample was lower than in previous studies.

LIMITATIONS

The small sample size, coupled with attrition rates, makes it difficult to generalise the findings of the study to HFASD population and to conduct analyses regarding mediators, moderators and predictors of outcomes.

CONCLUSIONS

The BRAVE-ONLINE program may be useful in reducing anxiety symptoms in HFASD children, although the effects are less strong than those found in neurotypical children for a variety of reasons.

A worrying trend in Social Anxiety: To what degree are worry and its cognitive factors associated with youth Social Anxiety Disorder?

BACKGROUND

Comorbidity between Social Anxiety Disorder (SAD) and Generalized Anxiety Disorder (GAD) is extremely common. This study investigated whether factors commonly associated with GAD, including worry, intolerance of uncertainty (IU), positive and negative beliefs about worry (PBW, NBW), negative problem orientation (NPO) and cognitive avoidance (CA) were associated with SAD severity, symptoms and overall functioning.

METHOD

Participants included 126 youth aged 8-17 years (M=11.29, SD=2.67, Males n=50) with a primary diagnosis of SAD. Participants and a parent underwent a diagnostic interview and completed questionnaires at pre- and 12-week post assessment, and 6-month follow-up. Correlations and hierarchical multiple regression analyses were conducted.

RESULTS

Each of the cognitive variables, with the exception of PBW, was found to correlate with SAD symptoms, SAD severity and overall functioning. NPO emerged as an important predictor of SAD severity, self-reported ratings of SAD symptoms, and poorer levels of overall functioning. IU and worry also predicted self-rated SAD symptoms.

LIMITATIONS

Measures were chosen on the basis of their sound psychometrics however some were yet to undergo rigorous testing with youth populations. The study design is cross-sectional, which restricts firm conclusions regarding causal and temporal associations between the variables.

CONCLUSIONS

Findings from this study have implications for the specificity of GAD and SAD in youth. Further research is required to understand whether these cognitive variables play a maintaining role in youth SAD and the extent to which they might influence treatment.

Thinking about worry: Investigation of the cognitive components of worry in children

BACKGROUND

Despite being extensively studied in adults, investigation of worry and it's associated cognitive variables remains in its infancy in paediatric samples.

AIMS

This study aimed to investigate 1) whether the child cognitive variables of intolerance of uncertainty (IU), positive beliefs about worry (PBW), negative beliefs about worry (NBW), negative problem orientation (NPO) and cognitive avoidance (CA) were associated with child worry, 2) whether parental worry and cognitive variables were associated with child worry, 3) whether the relationship between child and parent worry was mediated by child cognitive variables and 4) whether the relationships between specific parent cognitive factors and child worry were mediated by specific child cognitive factors.

METHOD

Participants were 114 children plus one of their parents. Parents and children completed questionnaires assessing each of the five cognitive variables and worry.

RESULTS

When examined together, child NBW and CA significantly predicted child worry. Parent worry, IU and CA were significantly and positively related to child worry. The relationship between parent worry and child worry was mediated by child NBW and CA. The relationship between parent IU, NPO and CA and child worry was mediated by child IU, NPO and CA respectively.

CONCLUSIONS

Child NBW and CA may be particularly important to child worry and may represent potential treatment targets. Parental worry and cognitive variables may play a role in the development and / or maintenance of child worry.

A Parent-Mediated, Cognitive Behavioral Therapy Group Treatment for Young Children With High-Functioning Autism Spectrum Disorder and Comorbid Anxiety: Development and Case Illustration of the Fun With Feelings Program

Comorbid anxiety is increasingly being recognized as a significant concern in children with high-functioning autism spectrum disorder (HFASD; Selles & Storch, 2013). Given the significant short and long term impact of anxiety on the functioning of a child with autism spectrum disorder (ASD; e.g., Bellini, 2004; Ben-Sasson et al., 2008), it is imperative that children with HFASD and comorbid anxiety receive intervention as early as is possible. Despite this need, there is a currently a dearth of research examining anxiety management programs for young children with HFASD. This article describes the development of a parent-mediated, cognitive behavioral therapy, group program for anxiety in 4- to 6-year-old children with HFASD. It provides a detailed discussion of the strategies taught to parents and children and highlights some of the challenges involved. A case study is also presented to illustrate progression and outcomes brought about through the program.

Logging into therapy: Adolescent perceptions of online therapies for mental health problems

OBJECTIVES

This study describes adolescent attitudes towards online therapies and explores the factors that predict these attitudes.

METHOD

Australian adolescents (N = 217) were surveyed on their knowledge of, attitudes towards (including perceived problems, perceived benefits, and perceived helpfulness), recommended availability of, and intentions to use online therapies. In addition, demographic and clinical factors, factors relating to technology use, adolescents' mental health attitudes, and personality traits were also measured.

RESULTS

The findings suggested that 72.0% of adolescents would access an online therapy if they experienced a mental health problem and 31.9% would choose an online therapy over traditional face-to-face support. The most valued benefits of these programs included alleviation of stigma and increased accessibility. Knowledge of online therapies was found to positively predict perceived helpfulness and intended uptake.

CONCLUSIONS

This study provides insight into adolescent attitudes towards online therapies and highlights the need to investigate strategies for increasing uptake.

Generic versus disorder specific cognitive behavior therapy for social anxiety disorder in youth: A randomized controlled trial using internet delivery

The study examined whether the efficacy of cognitive behavioral treatment for Social Anxiety Disorder for children and adolescents is increased if intervention addresses specific cognitive and behavioral factors linked to the development and maintenance of SAD in young people, over and above the traditional generic CBT approach. Participants were 125 youth, aged 8-17 years, with a primary diagnosis of SAD, who were randomly assigned to generic CBT (CBT-GEN), social anxiety specific CBT (CBT-SAD) or a wait list control (WLC). Intervention was delivered using a therapist-supported online program. After 12-weeks, participants who received treatment (CBT-SAD or CBT-GEN) showed significantly greater reduction in social anxiety and post-event processing, and greater improvement in global functioning than the WLC but there was no significant difference between CBT-SAD and CBT-GEN on any outcome variable at 12-weeks or 6-month follow-up. Despite significant reductions in anxiety, the majority in both treatment conditions continued to meet diagnostic criteria for SAD at 6-month follow-up. Decreases in social anxiety were associated with decreases in post-event processing. Future research should continue to investigate disorder-specific interventions for SAD in young people, drawing on evidence regarding causal or maintaining factors, in order to enhance treatment outcomes for this debilitating condition.

Does an Online CBT Program for Anxiety Impact Upon Sleep Problems in Anxious Youth?

This study aimed to assess whether the transdiagnostic therapy elements of an online cognitive behaviour therapy anxiety program also impact on sleep-related problems (SRPs) in anxious youth. Participants were drawn from two previously published studies evaluating online cognitive behaviour therapy for child anxiety (BRAVE-ONLINE). The study included 63 children 7-12 years of age (M = 9.49, SD = 1.37) and 71 adolescents 12-18 years of age (M = 13.90, SD = 1.68). SRPs, severity of anxiety diagnosis, anxiety symptoms, number of diagnoses, depressive symptoms, and global functioning were assessed at pre-, post-, and 6-month follow-up assessment points. SRPs were positively related to anxiety symptoms and severity for children and were positively related to depression for adolescents. SRPs did not differ between male and female participants, between children and adolescents, or between those who had generalised anxiety disorder in their profile and those who did not. Finally, children but not adolescents participating in the online program demonstrated a significantly greater reduction in SRPs from pre- to posttreatment compared to the waitlist group, and these gains were maintained at 6-month follow-up. Treatment focusing on child anxiety alone may reduce SRPs in children but not adolescents. Although further research is clearly needed, clinicians should ensure that they assess for SRPs in their teenage clients and directly target SRPs in treatment where required.

Is athletic really ideal? An examination of the mediating role of body dissatisfaction in predicting disordered eating and compulsive exercise

BACKGROUND

Investigations into female body image have suggested that rather than thinness, preference is now being given to a female "athletic ideal" characterised by a toned abdomen, firmer lower body and muscular upper body. This study sought to investigate a) whether greater internalization of the athletic-ideal is associated with higher body dissatisfaction, dieting, bulimic symptoms and compulsive exercise, and b) whether body dissatisfaction mediates the relationship between athletic-ideal internalization and the disordered eating and exercise behaviours of dieting, bulimic symptoms and compulsive exercise.

METHODS

Participants were 388 females aged between 17 and 35years. Participants completed a battery of questionnaires measuring athletic-ideal internalization, body dissatisfaction, dieting, compulsive exercise and bulimic symptoms.

RESULTS

Athletic-ideal internalization was not found to be associated with body dissatisfaction, but was found to predict dieting, bulimic symptoms and compulsive exercise directly. Body dissatisfaction did not mediate the relationship between athletic-ideal internalization and any of the disordered eating and exercise behaviours.

LIMITATIONS

The study was limited by its cross sectional design which precluded conclusions being drawn about the direction of causality and temporal associations.

CONCLUSIONS

Athletic-ideal internalization, while not associated with body dissatisfaction, was associated with a range of disordered eating and exercise behaviours. Results from the study suggest that the female athletic-ideal is an equally unrealistic and problematic ideal for women to strive towards.

A test of athletic internalisation as a mediator in the relationship between sociocultural influences and body dissatisfaction in women

The tripartite model has been an important and empirically supported theoretical model positing that the influence of peers, family, and media leads women to internalise the thin societal body ideal. This internalisation in turn leads women to experience body dissatisfaction. Recently, a new societal 'athletic ideal' for women has emerged, which promotes a body frame with pronounced lean muscle mass. This study tested the role of the athletic ideal in the tripartite model of influence with a sample of 421 women aged 17-40 years. Athletic ideal internalisation was neither found to be associated with body dissatisfaction, nor act as a mediator in the relationship between sociocultural influences and body dissatisfaction. Although more research is required, the results of this study suggest that for this cross-sectional sample of women, internalisation of an athletic and muscular, rather than thin ideal, may be less detrimental to body satisfaction.

Investigation of the cognitive variables associated with worry in children with Generalised Anxiety Disorder and their parents

BACKGROUND

Intolerance of uncertainty (IU), negative beliefs about worry (NBW), positive beliefs about worry (PBW), negative problem orientation (NPO) and cognitive avoidance (CA) have been found to be integral in the conceptualisation of Generalised Anxiety Disorder (GAD) in adults, yet they have rarely been investigated in children with GAD. This study sought to determine (a) whether IU, NBW, PBW, NPO and CA differ between children diagnosed with GAD and non-anxious children and (b) to examine whether IU, NBW, PBW, NPO and CA differ between parents of children diagnosed with GAD and parents of children without an anxiety disorder.

METHODS

Participants were 50 children (aged 7-12 years), plus one of their parents. The 25 GAD children and 25 non-anxious children were matched on age and gender. Parents and children completed clinical diagnostic interviews, as well as a battery of questionnaires measuring worry, IU, NBW, PBW, NPO and CA.

RESULTS

Children with GAD endorsed significantly higher levels of worry, IU, NBW, NPO and CA, but not PBW compared to non-anxious children. Parents of children with GAD did not differ from parents of non-anxious children on any of the variables.

LIMITATIONS

The study was limited by it's use of modified adult measures for some variables and a lack of heterogeneity in the sample.

CONCLUSIONS

The cognitive variables of IU, NBW, NPO and CA may also be important in the conceptualisation and treatment of GAD in children as they are in adults.

Intensive group-based CBT for child social phobia: a pilot study

OBJECTIVE

Although CBT has proven efficacious in the treatment of child social phobia (SP), most children do not present for treatment and child SP may be less responsive to treatment than other anxiety disorders. Intensive, group-based, SP-specific CBT may improve the efficacy of, and access to, treatment for child SP. The aim of this study was to provide a preliminary examination of such a program.

METHOD

Forty Australian children aged 7-12 years (15 male and 25 female) were allocated into treatment and waitlist groups. Clinical interviews to determine diagnostic status were conducted prior to treatment, following treatment and at 6-month follow-up. Parent and child questionnaire measures of child anxiety symptoms, internalizing symptoms, depression, social skills, social competence, and parental social anxiety were administered at the same time points. Treatment was delivered in 4 separate 3-hour sessions conducted over 3 consecutive weekends.

RESULTS

At postassessment, 52.4% of children in the treatment group and 15.8% of children in the waitlist group were free of their SP diagnosis. At postassessment, compared to waitlist children, treatment group children demonstrated a greater drop in clinical severity, a greater increase in overall functioning, and held fewer clinical diagnoses. Treatment group children also reported a greater reduction in SP symptoms compared to waitlist children, and treatment group parents reported a greater reduction in child internalizing and anxiety symptoms, a greater increase in child social competence, and a greater decrease in parental SP symptoms, compared to parents of children in the waitlist group. By 6-month follow-up, 76.9% of the treatment group were free of their SP diagnosis and gains on all other measures were maintained.

CONCLUSIONS

The results of this study are encouraging, and suggest that brief, intensive, group CBT for children with social anxiety is beneficial for many youngsters.

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.

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, η(p) (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, η(p) (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;

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.

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.