Internet-Based Cognitive-Behavioral Intervention Therapy for Child Anxiety
Internet-Based Cognitive-Behavioral Intervention Therapy for Child Anxiety
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.
Between 5% to 10% of children and adolescents experience clinically significant anxiety disorders (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Essau, Conradt, & Petermann, 2000, 2002), and, if left untreated, such problems may result in a number of adverse academic, vocational, and social consequences (Costello, Angold, & Keeler, 1999; Ginsburg, La Greca, & Silverman, 1998; Last, Hansen, & Franco, 1997). Cognitive-behavioral therapy (CBT) has been shown to be highly effective in treating child anxiety disorders (see James, Soler, & Weatherall, 2005, for a review). Indeed, between 50% and 85% of youth receiving CBT no longer meet criteria for their primary anxiety diagnosis at the end of treatment (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Kendall et al., 1997), with effects maintained up to several years later (Barrett, Duffy, Dadds, & Rapee, 2001; Kendall & Southam-Gerow, 1996).
Despite the efficacy of CBT interventions, the vast majority of children with anxiety do not receive treatment (Essau et al., 2000). This may reflect the family's failure to realize that there is a problem, a lack of knowledge about the availability of treatment, lack of local mental health services, and constraints on the family in terms of time or finances (Booth et al., 2004). Clearly, there is a need to provide CBT for child anxiety that is easy for families to access.
In recent years, computer-based technologies have been used to increase access to health and mental health services. Such methods include palm-top computers, e-mail, the World Wide Web (Internet), DVDs, CD-ROMs, virtual reality, and interactive voice messaging systems (Griffiths & Christensen, 2006; Newman, 2004). CBT has lent itself particularly well to computerization given its highly structured procedures and format (Anderson, Jacobs, & Rothbaum, 2004; Proudfoot, 2004).
To date, the majority of research investigating the impact of computer and online CBT for anxiety disorders has involved adult populations, and the results have been largely positive in the treatment of a range of anxiety disorders (see Griffiths & Christensen, 2006, for a review). Generally, the results suggest that computer-based CBT for adult anxiety produces small but significant reductions in anxiety when treatment is completed on a self-help basis, with effects being more substantial if accompanied by regular therapist contact, by phone, e-mail, or face-to-face (Spek et al., 2007).
It remains to be determined whether such methods can be effectively used in the treatment of childhood anxiety. The lack of development and evaluation of computer-based interventions for childhood disorders is particularly surprising given that children are generally highly skilled in the use of computer technologies (Calam, Cox, Glasgow, Jimmieson, & Larsen, 2000), and that the Internet has become a commonly used source for seeking help, particularly for adolescents (Nicholas, Oliver, Lee, & O'Brien, 2004).
The limited research relating to computer-based interventions for childhood anxiety has demonstrated positive outcomes in case studies of spider phobia (Nelissen, Muris, & Merckelbach, 1995) and selective mutism (Fung, Manassis, Kenny, & Fiksenbaum, 2002), as well as a small randomized controlled trial of the treatment of spider phobia in children (Dewis et al., 2001). In addition, a recent randomized controlled trial conducted by Spence, Holmes, March, & Lipp (2006), demonstrated positive outcomes for a CBT intervention, in which half the sessions were presented over the Internet and half in the clinic. Compared to no-intervention program, the partially Internet-based program produced significant reductions in anxiety symptoms. Further, there were only minimal differences between the combined Internet- and clinic-based treatment and the entirely clinic-based intervention. This study demonstrated the feasibility of transforming at least some parent and child CBT sessions into Internet format, with only minimal reductions in therapeutic outcome.
To date, there does not appear to have been a larger scale randomized controlled trial to evaluate the impact of CBT for child anxiety when delivered entirely over the Internet. The present study reports the findings of such a trial in which a CBT program involving both parent and child sessions was administered entirely via the Internet, supplemented by minimal therapist assistance via telephone and e-mail. Efficacy was evaluated by comparing the Internet therapy with a wait-list (WL) control condition, from pretreatment to posttreatment, with the outcomes of therapy being reassessed at 6-month follow-up. Fortunately, there are now a number of studies that demonstrate large effect sizes for clinic-based CBT for child anxiety (Ishikawa, Okajima, Matsuoka, & Sakano, 2007), which will allow us to make comparisons with the online intervention in this study.
Abstract and Introduction
Abstract
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.
Introduction
Between 5% to 10% of children and adolescents experience clinically significant anxiety disorders (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Essau, Conradt, & Petermann, 2000, 2002), and, if left untreated, such problems may result in a number of adverse academic, vocational, and social consequences (Costello, Angold, & Keeler, 1999; Ginsburg, La Greca, & Silverman, 1998; Last, Hansen, & Franco, 1997). Cognitive-behavioral therapy (CBT) has been shown to be highly effective in treating child anxiety disorders (see James, Soler, & Weatherall, 2005, for a review). Indeed, between 50% and 85% of youth receiving CBT no longer meet criteria for their primary anxiety diagnosis at the end of treatment (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Kendall et al., 1997), with effects maintained up to several years later (Barrett, Duffy, Dadds, & Rapee, 2001; Kendall & Southam-Gerow, 1996).
Despite the efficacy of CBT interventions, the vast majority of children with anxiety do not receive treatment (Essau et al., 2000). This may reflect the family's failure to realize that there is a problem, a lack of knowledge about the availability of treatment, lack of local mental health services, and constraints on the family in terms of time or finances (Booth et al., 2004). Clearly, there is a need to provide CBT for child anxiety that is easy for families to access.
In recent years, computer-based technologies have been used to increase access to health and mental health services. Such methods include palm-top computers, e-mail, the World Wide Web (Internet), DVDs, CD-ROMs, virtual reality, and interactive voice messaging systems (Griffiths & Christensen, 2006; Newman, 2004). CBT has lent itself particularly well to computerization given its highly structured procedures and format (Anderson, Jacobs, & Rothbaum, 2004; Proudfoot, 2004).
To date, the majority of research investigating the impact of computer and online CBT for anxiety disorders has involved adult populations, and the results have been largely positive in the treatment of a range of anxiety disorders (see Griffiths & Christensen, 2006, for a review). Generally, the results suggest that computer-based CBT for adult anxiety produces small but significant reductions in anxiety when treatment is completed on a self-help basis, with effects being more substantial if accompanied by regular therapist contact, by phone, e-mail, or face-to-face (Spek et al., 2007).
It remains to be determined whether such methods can be effectively used in the treatment of childhood anxiety. The lack of development and evaluation of computer-based interventions for childhood disorders is particularly surprising given that children are generally highly skilled in the use of computer technologies (Calam, Cox, Glasgow, Jimmieson, & Larsen, 2000), and that the Internet has become a commonly used source for seeking help, particularly for adolescents (Nicholas, Oliver, Lee, & O'Brien, 2004).
The limited research relating to computer-based interventions for childhood anxiety has demonstrated positive outcomes in case studies of spider phobia (Nelissen, Muris, & Merckelbach, 1995) and selective mutism (Fung, Manassis, Kenny, & Fiksenbaum, 2002), as well as a small randomized controlled trial of the treatment of spider phobia in children (Dewis et al., 2001). In addition, a recent randomized controlled trial conducted by Spence, Holmes, March, & Lipp (2006), demonstrated positive outcomes for a CBT intervention, in which half the sessions were presented over the Internet and half in the clinic. Compared to no-intervention program, the partially Internet-based program produced significant reductions in anxiety symptoms. Further, there were only minimal differences between the combined Internet- and clinic-based treatment and the entirely clinic-based intervention. This study demonstrated the feasibility of transforming at least some parent and child CBT sessions into Internet format, with only minimal reductions in therapeutic outcome.
To date, there does not appear to have been a larger scale randomized controlled trial to evaluate the impact of CBT for child anxiety when delivered entirely over the Internet. The present study reports the findings of such a trial in which a CBT program involving both parent and child sessions was administered entirely via the Internet, supplemented by minimal therapist assistance via telephone and e-mail. Efficacy was evaluated by comparing the Internet therapy with a wait-list (WL) control condition, from pretreatment to posttreatment, with the outcomes of therapy being reassessed at 6-month follow-up. Fortunately, there are now a number of studies that demonstrate large effect sizes for clinic-based CBT for child anxiety (Ishikawa, Okajima, Matsuoka, & Sakano, 2007), which will allow us to make comparisons with the online intervention in this study.