Internet-delivered CBT for children with anxiety disorders : effect and prerequisites for implementation within public health care

Abstract: Background: Anxiety disorders are among the most common mental health problems in children and, if left untreated, increase the risk of impairment and psychiatric illness in the future. Although cognitive behavior therapy (CBT) is a recommended treatment for pediatric anxiety disorders, a large proportion of children do not receive CBT. Internet-delivered CBT (ICBT) is an effective treatment for a range of psychiatric disorders in adults and could be a way of increasing availability to treatment for children. Aims: The aim of the present thesis was to develop and evaluate ICBT for children (8-12 years of age) with a diagnosed anxiety disorder, and to investigate important prerequisites for implementation within regular health care. Specifically, we aimed to investigate the efficacy and feasibility of ICBT for children with specific phobia (study I), evaluate the effect of ICBT for children with anxiety disorders (study II), explore the long-term effects of ICBT (study III), investigate potential predictors of treatment outcome (study III), and explore clinicians attitudes to ICBT for children and adolescents (study IV). Methods: A technical platform for delivering treatment over the internet and a therapistguided CBT-based treatment program was developed. To test the preliminary feasibility and effect of ICBT, study I included 30 families with a child with a principal diagnosis of specific phobia. They received ICBT for six weeks and were assessed post-treatment and threemonths later. Study II randomized 93 families with a child with an anxiety disorder to either ICBT or a waitlist control condition. All participants were assessed ten weeks later, and those randomized to ICBT were also assessed three months after post-treatment. Study III was a long-term follow-up (3 and 12 months) of participants in study II, and included analyses of outcome predictors. Study IV was a survey study conducted at 15 randomly selected CAMHS-units in Sweden, with a total of 156 participating clinicians. Results: Studies I and II showed large within-group effects on clinician rated symptom severity and moderate effects on parent-rated child anxiety. Study II showed that the ICBT group had improved significantly more than the waitlist group at post-treatment. Improvements in the ICBT group continued until three- and twelve-month follow-up (study IIII). About a fifth of those who received ICBT did not fulfill criteria for their principal anxiety disorder at post-treatment, and this proportion increased to about 50% at three-month follow-up (studies I-III). In study IV, we found that clinicians reported seeing several advantages with ICBT and would consider using ICBT for children with mild to moderate problems. Conclusions: Guided ICBT for children with anxiety disorders could be effective in reducing clinician- and parent-ratings of anxiety. ICBT seems to be a promising method, although there is room for improvement. Most clinicians within Swedish CAMHS-units were largely positive towards using ICBT with children and adolescents, especially for mild to moderate problems. Thus, ICBT holds promise for future implementation within regular health care.