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A randomized controlled trial in community mental health centers of computer-assisted cognitive-behavioral therapy versus treatment as usual for children with anxiety

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Objective This study aims to examine the real-world effectiveness of a computer-assisted cognitive behavioral therapy (CBT) protocol relative to treatment as usual (TAU) among anxious children presenting at community mental health centers.Methods One hundred children (7–13 years) with clinically significant anxiety were randomized to receive either 12 weekly computer-assisted CBT sessions or TAU for an equivalent duration. Assessments were conducted by independent evaluators at screening/baseline, midtreatment, posttreatment, and 1-month followup (for computer-assisted CBT treatment responders).ResultsThere were significant between-group effects favoring the computer-assisted CBT condition on primary anxiety outcomes. Thirty of 49 (61.2%) children randomized to computer-assisted CBT responded to treatment, which was superior to TAU (6/51, 11.8%). Relative to TAU, computer-assisted CBT was associated with greater reductions in parent-rated child impairment and internalizing symptoms, but not child-rated impairment and anxiety and depressive symptoms. Treatment satisfaction and therapeutic alliance in those receiving computer-assisted CBT was high. Treatment gains in computer-assisted CBT responders were maintained at 1-month followup.Conclusions Within the limitations of this study, computer-assisted CBT is an effective and feasible treatment for anxious children when used in community mental health centers by CBT-naïve clinicians.
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DEPRESSION AND ANXIETY 32:843–852 (2015)
Research Article
A RANDOMIZED CONTROLLED TRIAL IN COMMUNITY
MENTAL HEALTH CENTERS OF COMPUTER-ASSISTED
COGNITIVE BEHAVIORAL THERAPY VERSUS
TREATMENT AS USUAL FOR CHILDREN WITH ANXIETY
Eric A. Storch, Ph.D.,1,2, 3,4, 5,6 Alison Salloum, Ph.D.,7Morgan A. King, B.A.,1Erika A. Crawford, B.A.,8
Ross Andel, Ph.D.,9Nicole M. McBride, B.S.,1and Adam B. Lewin, Ph.D.1,3, 4
Objective: This study aims to examine the real-world effectiveness of a computer-
assisted cognitive behavioral therapy (CBT) protocol relative to treatment as usual
(TAU) among anxious children presenting at community mental health centers.
Methods: One hundred children (7–13 years) with clinically significant anxi-
ety were randomized to receive either 12 weekly computer-assisted CBT sessions
or TAU for an equivalent duration. Assessments were conducted by independent
evaluators at screening/baseline, midtreatment, posttreatment, and 1-month fol-
lowup (for computer-assisted CBT treatment responders). Results: There were
significant between-group effects favoring the computer-assisted CBT condition
on primary anxiety outcomes. Thirty of 49 (61.2%) children randomized to
computer-assisted CBT responded to treatment, which was superior to TAU
(6/51, 11.8%). Relative to TAU, computer-assisted CBT was associated with
greater reductions in parent-rated child impairment and internalizing symp-
toms, but not child-rated impairment and anxiety and depressive symptoms.
Treatment satisfaction and therapeutic alliance in those receiving computer-
assisted CBT was high. Treatment gains in computer-assisted CBT responders
were maintained at 1-month followup. Conclusions: Within the limitations
of this study, computer-assisted CBT is an effective and feasible treatment for
anxious children when used in community mental health centers by CBT-na¨
ıve
1Rothman Center for Neuropsychiatry, Department of
Pediatrics, University of South Florida, St. Petersburg,
Florida
2Department of Health Policy and Management, University of
South Florida, St. Petersburg, Florida
3Department of Psychiatry and Behavioral Neurosciences,
University of South Florida, St. Petersburg, Florida
4Department of Psychology, University of South Florida, St.
Petersburg, Florida
5Rogers Behavioral Health – Tampa Bay, Florida
6Mind–Body Branch, All Children’s Hospital – Johns Hopkins
Medicine, St. Petersburg, Florida
7School of Social Work, University of South Florida, St. Peters-
burg, Tampa Bay, Florida
8Department of Psychology, Temple University, Philadelphia,
Pennsylvania
9School of Aging Studies, University of South Florida, St. Pe-
tersburg, Florida
Contract grant sponsor: This work was supported by a grant to the
first author from the Agency for Healthcare Research and Quality
(R18HS018665). The content is solely the responsibility of the au-
thors and does not represent the official views of the Agency for
Healthcare Research and Quality.
Clinicaltrials.gov Registration: NCT01416805
Correspondence to: Eric A. Storch, Rothman Center for Neuropsy-
chiatry, Department of Pediatrics, University of South Florida, Box
7523, 880 6th Street South, St. Petersburg, FL 33701.
E-mail: estorch@health.usf.edu
Received for publication 8 April 2015; Revised 26 June 2015; Ac-
cepted 30 June 2015
DOI 10.1002/da.22399
Published online 14 September 2015 in Wiley Online Library
(wileyonlinelibrary.com).
C2015 Wiley Periodicals, Inc.
844 Storch et al.
clinicians. Depression and Anxiety 32:843–852, 2015. C2015 Wiley Periodicals,
Inc.
Key words: anxiety; children; computer-assisted cognitive behavioral therapy;
treatment; community mental health centers
INTRODUCTION
Childhood anxiety disorders are common,[1–7]
impairing,[8] and run a chronic course without appro-
priate treatment.[9–11] Untreated childhood anxiety
may intensify in adulthood and confer additional risk
for sustained impairment and developing co-occurring
mood or substance abuse disorders.[12–14] Both cognitive
behavioral therapy (CBT) and serotonin reuptake
inhibitor (SRI) medications have demonstrated effi-
cacy for childhood anxiety.[15–18] Although the largest
multimodal treatment trial of pediatric anxiety to date
suggests that patients receive CBT alone (mild and
moderate cases) or with an SRI (moderate-to-severe
cases),[17] CBT dissemination is limited and many youths
are provided with non-evidence-based psychotherapy
or pharmacologic interventions.[19–22]
To improve CBT dissemination while maintaining
treatment fidelity, computer-assisted and computer-
based CBT programs have been developed.[23–27]
Computer-based programs differ from computer-
assisted protocols in which the former provides
intervention exclusively through an online, sequential
format, whereas the latter integrates a computer in-
tervention platform together with therapist-directed
support during some or all of the sessions. Computer-
based CBT for anxious youth has demonstrated efficacy
and treatment acceptability,[28] and preliminary data
among adults suggest lower cost.[29] Computer-assisted
CBT treatment programs have demonstrated similar
efficacy to in-person CBT[27] and, relative to computer-
based approaches, are more flexible for addressing
clinical complexities and demonstrate greater patient
acceptability.[26] Using computer-assisted programs for
treating pediatric anxiety may be particularly beneficial
given the structured treatment framework conducive
to introducing therapeutic concepts; for example,
psychoeducation and coping skills.[26, 27]
The literature on computer-assisted and computer-
based CBT programs has yielded promising preliminary
data for pediatric anxiety[27, 30,31] and depression.[32–34]
Beyond preliminary reports,[35–37] two randomized trials
of computer-assisted CBT have been published. Khanna
and Kendall[27] randomized 49 children (ages 7–13) to ei-
ther a computer-assisted CBT protocol (Camp Cope-A-
Lot);[26] individual CBT; or computer-linked education,
support, and attention (CESA). Therapists were clinical
psychology doctoral candidates, school psychologists, or
clinical psychologists described as having limited CBT
experience. Children randomized to computer-assisted
CBT and individual CBT (which did not differ) had
superior outcomes relative to CESA in remission rate
(81 and 70% vs. 19%), and clinician ratings of anxi-
ety severity (μ2=.31) and global functioning (μ2=
.38). Spence et al.[31] randomized 72 youths (ages 7–
14) with a primary anxiety diagnosis to a dual internet-
CBT arm (CLIN-NET), group CBT, or a waitlist for
10 weeks. The CLIN-NET program delivered five child
sessions via the internet and five sessions in a clinic-based
group treatment format (together with six parent ses-
sions, three of which were delivered via the internet).
The group CBT arm consisted of the same number of
sessions that were all delivered in person. Treatment was
conducted in a university clinic by psychologists trained
in CBT for pediatric anxiety. Both the CLIN-NET and
group CBT were superior to waitlist in primary anxiety
disorder remission rate (56 and 65% vs. 13%) and clin-
ician ratings of anxiety severity (μ2=.30), parent-rated
anxiety (μ2=.12), and child-rated anxiety (μ2=.18).
Collectively, the available literature supports the
preliminary efficacy and feasibility of computer-assisted
CBT for pediatric anxiety. Computer-assisted CBT
programs may be an efficient and effective way to
disseminate standardized care and evidence-based
treatments across multiple facilities (i.e., school, com-
munity mental health centers, medical settings, training
programs, social service agencies, counseling centers,
private clinics)[24] and could help to address concerns re-
garding the lack of evidence-based treatments available
in community settings as well as patients’ lack of access
to mental health care facilities offering empirically
supported treatments.[19–22] Although initial results
are promising for the two different computer-assisted
CBT approaches, there are several areas upon which
the extant literature can be expanded. First, to achieve
status as a “probably efficacious” or “well-established”
treatment, research groups other than the developers
must demonstrate efficacy.[38] To date, Camp Cope-
A-Lot—the intervention examined in this study—has
only been investigated by the treatment developers
in a single randomized-controlled trial. Second, data
regarding the utility of computer-assisted CBT con-
ducted by CBT-na¨
ıve therapists for childhood anxiety
in community mental health centers is lacking. Relative
to specialty clinics, this setting represents the ideal
location to evaluate the utility of computer-assisted
CBT given the above-noted concerns. Third, expanding
the measurement platform to incorporate continuous
assays of clinician-rated anxiety severity would allow for
cross-study comparability with gold-standard clinical
trials.[17] Finally, Camp Cope-A-Lot may be particu-
larly cost-effective and straightforward to disseminate;
Depression and Anxiety
Research Article: Computer-assisted CBT 845
Figure 1. Study flow chart.
Khanna and Kendall[27] described a short training
followed by brief weekly consultations to successfully
implement the treatment protocol.
The present study examines the real-world effective-
ness of Camp Cope-A-Lot[26] relative to treatment as
usual (TAU) in treating youth with anxiety. This study
uniquely contributes to the literature as the second test
of the intervention by an independent research group in
an externally valid clinical setting using a comprehensive
measurement platform. Relative to TAU, we predicted
that those randomized to computer-assisted CBT would
show greater reductions in clinician-rated anxiety symp-
toms, and higher response and remission rates. We also
expected to find greater reductions in parent-rated child
anxiety, internalizing symptoms and functional impair-
ment, and child-rated anxiety and depressive symptoms
in those receiving computer-assisted CBT relative to
TAU. Finally, we examined the short-term durability of
gains in computer-assisted CBT treatment responders,
and metrics of treatment acceptability (i.e., alliance, sat-
isfaction).
METHOD
PARTICIPANTS
One hundred twenty-three children (ages 7–13, inclusive) were re-
cruited and screened through the normal patient flow at three Florida
outpatient community mental health centers, distributed at minimum
200 miles apart (Panhandle, Central Coast, and Southeastern Florida).
Eligible subjects were enrolled from June 2012 to June 2014. Twenty-
three youths failed to meet inclusion/exclusion criteria (see Fig. 1),
resulting in a final sample of 100 youths (age: M=9.82, SD =1.82).
Participants met the following inclusion criteria: (i) primary anxiety
diagnosis of separation anxiety disorder (SAD), social phobia, gener-
alized anxiety disorder (GAD), specific phobia, or panic disorder, as
determined by the Anxiety Disorders Interview Schedule for DSM-IV-
Child and Parent Versions (ADIS-IV-C/P)[39] with a Clinical Severity
Rating (CSR) 4—the independent evaluator, in consensus with a
review team led by the last author, determined the primary and co-
morbid diagnoses based upon degree of impairment/distress and all
other available clinical information; (ii) minimum score of 10 on the
Pediatric Anxiety Rating Scale (PARS),[40] which corresponds to sig-
nificant anxiety[41]; and (iii) reading ability SS =85 on the Word
Reading section of the Wide Range Achievement Test 4th Edition.[42]
Exclusion criteria were as follows: (i) concurrent psychotherapy or
other counseling services specifically targeting anxiety—families were
able to maintain or initiate services if randomized to TAU; (ii) initi-
ation of an antidepressant or antipsychotic medication within 6 and
12 weeks of study enrollment, respectively (Antidepressants and an-
tipsychotics were stable for 6 and 8 weeks prior to screening, and stable
throughout treatment although dosage reductions due to side effects
were allowed in the computer-assisted CBT group. As with therapeutic
services, youth randomized to TAU were allowed to initiate or adjust
pharmacological interventions.); (iii) active suicidality or engagement
in suicidal behaviors within 6 months of screening; and (iv) bipolar
disorder, psychosis, or autism.
PROCEDURES
All study procedures were approved by the local Institutional Re-
view Board. Referrals were phone-screened by site-specific staff; chil-
dren who appeared to meet eligibility criteria were scheduled for a
screening at which point written informed consent and assent from
the parent and child were obtained. Thereafter, a blinded independent
evaluator located at a university-based research center interviewed par-
ents and children separately via a secure internet platform using a web
camera while the other completed questionnaires. Eligible families
Depression and Anxiety
846 Storch et al.
were randomized in a 1:1 ratio into computer-assisted CBT or TAU.
Families participated in three or four assessments: screening/baseline,
midtreatment, posttreatment, and a 1-month follow-up assessment (for
computer-assisted CBT treatment responders). Posttreatment assess-
ments were completed within 1 week after the final computer-assisted
CBT session or approximately 13 weeks after screening for those ran-
domized to TAU. All assessments were audio-recorded; 20% of the
recorded PARS interviews were rated by a second rater for qual-
ity assurance (intraclass correlation =.87). Upon completion of the
posttreatment assessment, families randomized to TAU were offered
computer-assisted CBT treatment. At each assessment, families were
compensated $30.00.
TREATMENT
Camp Cope-A-Lot is a dual in-person and computerized CBT
program developed for childhood anxiety. Based on the Coping Cat
protocol,[43,44] children received 12 weekly 50- to 60-min sessions
(called “levels” to the family) provided at an outpatient community
mental health center. Though therapists were present at every visit,
the first six sessions were primarily delivered over the computer and
provided standardized content targeting the development of coping
skills for managing anxiety (i.e., affective education, relaxation train-
ing, misidentification and labeling of anxiety-related cognition, and
problem solving) through an interactive computer interface involving
the child participating in a virtual camping experience. Although we
had originally hoped that these six sessions would be completed at the
participant’s home to maximize the benefits of a computer-assisted
intervention (e.g., reduced demands for travel and time away from
work/school), variable access to the internet and our initial experi-
ences working with this clinical population suggested the benefit of
holding all visits in person and in office. Sessions 7–12 were primarily
therapist led and involved gradual exposure to feared stimuli. Parent
sessions were held at visits 3 and 7 to provide psychoeducation and
foster parental support (see [26] for a review of the treatment protocol).
Therapists were six CBT-na¨
ıve master’s level social workers or
mental health counselors (3.6 ±2.1 years since graduation, range 1–6
years). Prior to seeing children, therapists attended a 2-day workshop
on CBT and the Camp Cope-A-Lot program. In addition, weekly
consultation calls were held where cases were discussed with an expe-
rienced clinician. Each therapy session was audio-recorded and 20% of
those recordings were reviewed for treatment integrity and adherence
to the computer-assisted CBT protocol. Fidelity checks on an 11-item
5-point multidimensional scale[27] were rated for two randomly se-
lected therapy sessions (one session from 1–6 and one session from 7–
12) for each child. The fidelity checks yielded excellent for adherence
to session components (23.6/25.0), therapist competence (14.0/15.0),
therapist flexibility (4.8/5.0), and therapeutic alliance (9.7/10.0).
Treatment as Usual. Families randomized to TAU were free to
initiate, continue, change, or refrain from receiving any psychothera-
peutic or pharmacological interventions. The research team provided
referral information for local treatment options but otherwise did not
attempt to influence decisions. During acute intervention, 55.3% (n=
26/47 completers) of participants in the TAU condition received psy-
chological or psychiatric services, including psychotherapy (n=22,
46.8%), medication management (n=8, 17%), special education ser-
vices (n=5, 10.6%), case management services (n=4, 8.5%), and
family treatment/education (n=3, 6.4%). Of those receiving services,
18 youths received one service (38.3%), 4 received two services (8.5%),
2 received three services (4.3%), and 2 received three or more services
(4.3%).
MEASURES
ADIS-IV-C/P.[39] The ADIS-IV-C/P is clinician-administered
semistructured interviews that assess the presence and severity of
DSM-IV childhood anxiety, mood, and externalizing disorders. On a
0–8 scale, diagnostic presence and severity are established using a CSR
score 4. The ADIS-IV-C/P has demonstrated excellent psychomet-
ric properties, including interrater reliability,[45] and was administered
at screening, posttreatment, and follow-up assessments.
PARS.[40] The PARS is a psychometrically sound clinician-rated
scale measuring child anxiety symptom presence and severity over
the past week. The six-item PARS Severity Scale was utilized in this
study,[40] containing items that assess anxiety in terms of symptom
frequency, severity, severity of physical symptoms, avoidance, inter-
ference at home, and interference outside of the home (e.g., school,
peer relationships). The PARS was administered at baseline, midtreat-
ment, posttreatment, and follow-up assessments (baseline α=0.61).
Clinical Global Impressions-Severity and Clinical Global Impressions-
Improvement (CGI-Severity, CGI-Improvement).[46] The CGI-
Severity is a single-item rating made by the independent evaluator
(IE) reflecting the global severity, impairment, and/or distress
of anxiety symptoms, with scores ranging from 0 (no illness) to
6 (extremely severe symptoms). The CGI-Severity was rated at
baseline, midtreatment, posttreatment, and follow-up assessments.
The CGI-Improvement assesses the degree of improvement in
anxiety symptoms relative to screening. Anchors include “very much
worse” and “very much improved.” The CGI-Improvement was rated
at midtreatment, posttreatment, and follow-up assessments.
Service Assessment for Children and Adolescents-Service Use Scale
(SACA).[47] The SACA is a standardized questionnaire used to cap-
ture mental health services attained for the child (i.e., inpatient, out-
patient, school, family-based services). The SACA was administered at
baseline, posttreatment, and follow-up assessments.
Secondary Outcomes. All secondary measures were adminis-
tered at baseline, posttreatment, and follow-up assessments.
Child Behavior Checklist (CBCL).[48] The CBCL is a 118-item,
psychometrically sound,[48] parent-reported scale assessing the child’s
internalizing and externalizing symptoms. The Internalizing scale was
used to assess internalizing symptoms; the Externalizing scale was used
to assess disruptive behavior (baseline α=0.95).
Columbia Impairment Scale-Parent Version (CIS-P).[49] The CIS-
P is a psychometrically sound questionnaire that evaluates levels of
functional impairment in home, school, and social domains (baseline
α=0.85).[49]
Childhood Anxiety Impact Scale-Child/Parent (CAIS-C/P).[50] The
CAIS-C/P is a psychometrically sound[50, 51] child- and parent-report
measures assessing the impact of the child’s anxiety on his/her psy-
chosocial functioning in certain situations (school, social, home/family,
and globally) over the past month (baseline CAIS-C α=0.92 and
CAIS-P 0.91).
Multidimensional Anxiety Scale-Child (MASC).[52] The MASC is a
psychometrically sound[52] child-report measure of anxiety symptoms
(baseline α=0.89).
Children’s Depression Inventory (CDI).[53] The CDI is a psycho-
metrically sound[54] child-report assessment of depressive symptoms
with excellent predictive utility (baseline α=0.90).[55]
Therapeutic Alliance Scale-Child/Parent (TAS-C/P).[56] For those
randomized to computer-assisted CBT, the parent’s and child’s al-
liance with the therapist was measured at posttreatment with the TAS-
C/P. The TAS-C consists of 12 items whereas the TAS-P consists of
7 items; both are rated on a 4-point scale with higher scores indicative
of greater alliance (TAS-C α=0.83, TAS-P α=0.72).
Client Satisfaction Questionnaire-8 (CSQ-8).[57] For those random-
ized to computer-assisted CBT, satisfaction of the treatment program
was rated at posttreatment by both children and parents with the
Depression and Anxiety
Research Article: Computer-assisted CBT 847
CSQ-8, which is a psychometrically sound[58] 8-item measure rated
on a 4-point scale, with higher scores indicating greater satisfaction
(child CSQ-8 α=0.83, parent CSQ-8 α=0.83).
DATA ANALYSIS
The PARS Severity Scale, CGI-Severity, ADIS-IV-C/P CSR, treat-
ment response status, and remission were the primary outcomes. Ini-
tially, we compared participants assigned to computer-assisted CBT
versus TAU across demographic characteristics and sites to evaluate
any differences following randomization; no statistically significant dif-
ferences existed except for a difference in age (t[98] =2.4, P=.019).
Therefore, age was controlled in all subsequent analyses. In main anal-
yses, random effects models[59] in SAS (SAS Institute, Cary, NC) pro-
cedure MIXED were used to examine whether any changes in outcome
scores were a function of group assignment. Random effects model-
ing builds on a repeated measures analysis of variance in that it pro-
vides the same information but is more flexible with respect to analysis
of unbalanced designs. In addition, maximum-likelihood estimation
of effects allows for the inclusion of participants with missing data,
making it compliant with the intent-to-treat analytical approach. The
maximum-likelihood strategy is preferred over carrying last observa-
tion forward in studies like ours, especially when missing data do not
extend beyond 20%.[60] There were no more than 12% of data missing
on any of our outcome measures. For this study, the most important
output is the group-by-time interaction, which evaluates whether the
participants assigned to the computer-assisted CBT group changed at
differential rates over assessment points compared with participants in
the TAU group. Two of the outcomes were dichotomous—treatment
response and remission. Remission was defined as a CSR 3onthe
primary anxiety disorder diagnosis. A CGI-Improvement rating of
“much improved” or “very much improved” was used to designate
treatment response. These outcomes were evaluated using binary lo-
gistic regression in SAS procedure LOGISTIC, again controlling for
age. Dropouts were considered nonresponders/nonremitters. In addi-
tion to the main analyses, results were also obtained including only
those TAU group children who received services in the acute phase of
the trial (n=26).
Our sample size (N=100) across the two groups yielded statistical
power of .80 to detect the group-by-time interaction when the effect
size (Cohen’s d) reached 0.57, which is a moderate effect. Cohen’s dis
generally considered clinically meaningful when it reaches 0.5.[61]
RESULTS
Sample Characteristics. Sample characteristics are
presented in Table 1. There were no baseline group
differences except for age, where participants random-
ized to the TAU group were on average 0.8 years
older than those randomized to the computer-assisted
CBT group. After eligible participants were randomized,
four computer-assisted CBT and four TAU participants
dropped out or were withdrawn before completion due
to varied reasons (e.g., due to multiple no shows, un-
able to be contacted, or a higher level of care needed;
see Fig. 1). One participant in the computer-assisted
CBT group initiated an antidepressant; though when
this subject’s data were removed, findings remained
identical.
Primary Outcomes. Means, SDs, and results for
the group-by-time interaction are shown in Table 2.
The computer-assisted CBT group showed a more fa-
vorable change compared to the TAU group across
time points on the PARS, CGI-Severity, and ADIS-IV-
C/P CSR, with the baseline-to-posttreatment Cohen’s
dvalues suggesting moderate to large effect sizes (0.45,
0.62, and 0.76, respectively). When data for the TAU
group were restricted only to those children who re-
ceived services, the results for the primary outcomes re-
mained unchanged, with the effect sizes slightly larger
for each of the three outcomes (0.52, 0.78, and 0.89,
respectively).
With respect to treatment response, 30 of 49 (61.2%)
participants randomized to computer-assisted CBT ver-
sus 6 of 51 (11.8%) of participants in the TAU group
were responders. The odds of being a treatment respon-
der were 14 times greater in the computer-assisted CBT
arm compared with the TAU group (odds ratio =14.4,
P<.001). With respect to remission, 27 of 49 (55.1%)
participants in the computer-assisted CBT group versus
9 of 51 (17.6%) of the TAU group experienced remission
at posttreatment, amounting to approximately six times
greater odds of remission in the computer-assisted CBT
compared with the TAU group (odds ratio =6.05, P
<.001). When the TAU group restricted only to those
who received services, being a treatment responder was
almost 17 times more likely (odds ratio =16.8, P<.001)
and experiencing remission was about seven times more
likely (odds ratio =7.3, P=.002) with assignment to the
computer-assisted CBT group compared with the TAU
group.
Secondary Outcomes. Those randomized to
computer-assisted CBT exhibited more favorable
change in scores on the CBCL Internalizing and Ex-
ternalizing scales compared with those randomized to
TAU, with large between-group differences. We ob-
served significant improvement in scores on the CIS-P
and CAIS-P in the computer-assisted CBT arm relative
to TAU, whereas the group-by-time interaction was not
significant for the CDI, CAIS-C, and MASC scales (see
Table 2). When the TAU group included only children
who received services, a significant improvement in the
computer-assisted CBT over the TAU group was ob-
served only in CIS-P scale (Estimate =–6.39, P<.01,
Cohen’s d=0.82).
With regard to treatment alliance among those in the
computer-assisted CBT arm, children reported a mean
TAS-C score of 40.47 (SD =6.47) out of a total possible
score of 48. For parent–therapist therapeutic alliance,
parents reported a mean TAS-P score of 26.81 (SD =
1.72) out of a possible 28. Regarding treatment satisfac-
tion of those in the computer-assisted CBT arm, chil-
dren reported a mean CSQ-8 score of 28.02 (SD =4.06)
and parents reported a mean CSQ-8 score of 29.61 (SD
=3.31) out of a possible total of 32.
Retention of Gains at 1-month Followup. Those
who were randomized to computer-assisted CBT and
were classified as treatment responders at posttreatment
were re-assessed 1 month later (n=24, see Table 3). No
significant changes from posttreatment to followup were
observed on all outcomes except for a significant reduc-
tion in the CBCL Externalizing scale, suggesting that
Depression and Anxiety
848 Storch et al.
TABLE 1. Demographic and clinical information by treatment condition
Measure CCBT n=49 TAU n=51 P-value
Child sex (male, n[%]) 26 (53.1) 30 (58.8) .562
Child age (years [mean ±SD]) 9.4 ±1.8 10.2 ±1.8 .019
Parent (mother, n[%]) 46 (93.9) 48 (94.1) .716
Parent graduated from college (n [%]) 25 (51.0) 26 (51.0) .841
Child ethnicity/race .368
Caucasian 38 (77.6) 34 (66.7)
Hispanic 5 (10.2) 7 (13.7)
Black 4 (8.2) 7 (13.7)
Asian/Pacific Islander 2 (4.1) 1 (2.0)
Other 0 2 (3.9)
Living arrangement .462
With both parents/same residence 24 (49.0) 25 (49.0)
With both parents/different residences 6 (12.2) 5 (9.8)
Single parent 6 (12.2) 12 (23.6)
Biological parent and stepparent 3 (6.1) 2 (3.9)
Grandparents 1 (2.0) 3 (5.9)
Other 9 (18.4) 4 (7.8)
Primary anxiety disorder (n [%])
Separation anxiety 9 (18.4) 14 (27.5) .410
Social phobia 13 (26.5) 13 (25.5) .906
Specific phobia 4 (8.2) 5 (9.8) .774
Panic disorder 1 (2.0) 0
GAD 22 (44.9) 19 (37.3) .567
Other comorbid diagnoses
Separation anxiety disorder 8 (16.3) 5 (9.8)
Social phobia 7 (14.3) 3 (5.9)
Specific phobia 6 (12.2) 9 (17.7)
Agoraphobia with panic 0 1 (2.0)
GAD 7 (14.3) 18 (35.3)
OCD 2 (4.1) 4 (7.8)
PTSD 2 (4.1) 0
Dysthymia 0 3 (5.9)
Major depressive disorder 3 (6.1) 3 (5.9)
ADHD-inattentive 3 (6.1) 7 (13.7)
ADHD-combined 14 (28.6) 9 (17.7)
Conduct disorder 0 1 (2.0)
ODD 3 (6.1) 4 (7.8)
Selective mutism 2 (4.1) 3 (5.9)
Enuresis 2 (4.1) 3 (4.1)
Total number of diagnoses (mean ±SD)3.1±0.9 3.1 ±1.2 .793
Currently on medication (n[%]) 10 (20.4) 11 (21.6) .887
Family income .205
$40,000 or less 20 (44.4) 31 (62.0)
$40,001–$90,000 15 (33.3) 10 (20.0)
Over $90,000 10 (22.2) 9 (18.0)
CCBT, computer-assisted cognitive behavioral therapy; TAU, treatment as usual; PDD-NOS, pervasive developmental disorder not otherwise
specified; SAD, separation anxiety disorder; OCD, obsessive–compulsive disorder; GAD, generalized anxiety disorder; ADHD, attention deficit
hyperactivity disorder; MDD, major depressive disorder; ODD, oppositional defiant disorder; CD, conduct disorder; PTSD, posttraumatic stress
disorder.
responders assessed maintained their responder status at
followup.
To further examine this notion, we used the same
mixed effects models to estimate the overall trajectory of
change for the 24 responders first from baseline to post-
treatment, and then from baseline to followup. We found
that the slope estimates (indicating decline in baseline-
to-post or baseline-to-followup symptoms) were signif-
icant, although reduced when the follow-up time point
was added, for primary outcomes PARS (baseline to post:
Estimate =–3.58, P<.001; baseline to followup: Es-
timate =–2.72, P<.001), CGI-Severity (baseline to
post: Estimate =–0.63, P<.001; baseline to followup:
Estimate =–0.50, P<.001), and ADIS-IV-C/P CSR
(baseline to post: Estimate =–2.17, P<.001; baseline
to followup: Estimate =–1.33, P<.001), as well as the
Depression and Anxiety
Research Article: Computer-assisted CBT 849
TABLE 2. Results for primary and secondary outcomes at baseline, midtest, posttest, and followup
Baseline Midtest Posttest Group ×Time
Measure Group nMean SD Mean SD Mean SD Estimate Effect size d
Primary outcomes
PARS-Severity TAU 51 16.7 3.5 15.8 4.2 14.7 4.9
CCBT 49 16.5 3.3 13.3 4.7 11.4 5.2 1.44** 0.45
CGI-Severity TAU 51 3.5 0.5 3.3 0.7 3.2 0.9
CCBT 49 3.4 0.6 2.9 0.8 2.5 0.9 0.30** 0.62
ADIS CSR of primary anxiety diagnosis TAU 51 4.5 0.7 4.0 1.4
CCBT 49 4.6 0.7 3.0 1.3 1.29*** 0.76
Secondary outcomes
CDI TAU 50 11.0 9.2 9.4 8.4
CCBT 49 9.8 8.4 6.4 6.7 2.16 0.19
CBCL-Internalizing TAU 51 19.7 9.9 17.8 11.1
CCBT 49 17.3 8.0 10.9 8.1 3.68** 0.79
CBCL-Externalizing TAU 51 10.6 8.9 10.6 9.0
CCBT 49 11.2 8.8 7.1 6.8 3.17*0.75
CIS-Parent TAU 51 17.4 10.1 16.9 11.8
CCBT 49 19.3 8.9 12.3 8.6 6.08*** 0.80
CAIS-Child TAU 51 26.3 18.2 19.3 17.6
CCBT 49 23.8 16.0 14.5 15.8 1.17 0.19
CAIS-Parent TAU 51 31.5 15.9 25.2 15.6
CCBT 49 30.7 15.8 17.5 16.3 6.77*0.43
MASC TAU 51 54.3 19.2 50.8 22.6
CCBT 49 54.2 17.5 44.6 18.1 5.97 0.36
CCBT, computer-assisted cognitive behavioral therapy; TAU, treatment as usual; PARS, Pediatric Anxiety Rating Scale; CGI-Severity, Clinical
Global Impressions-Severity; ADIS, Anxiety Disorder Interview Schedule; CSR, Clinical Severity Rating; CDI, Children’s Depression Inventory;
CBCL, Child Behavior Checklist; CIS, Columbia Impairment Scale; CAIS, Childhood Anxiety Impact Scale; MASC, Multidimensional Anxiety
Scale for Children.
P<.05, ∗∗P<.01, ∗∗∗ P<.001.
Estimates (unstandardized regression coefficients) are based on random effects models. The effect size dsignifies the difference in average gain
scores (baseline to posttest) between the treatment and control groups.
secondary outcomes on which significant gains were ob-
served for the intervention relative to control group—
CIS-P (baseline to post: Estimate =–9.75, P<.001;
baseline to followup: Estimate =–5.17, P<.001) and
CAIS-P (baseline to post: Estimate =–19.67, P<.001;
baseline to followup: Estimate =–10.25, P<.001).
DISCUSSION
A computer-assisted CBT intervention (Camp Cope-
A-Lot)[26] was effective in reducing anxiety and related
impairment in children with clinically significant anxi-
ety who presented at community mental health centers.
These data build upon preliminary work by Khanna and
Kendall,[27] and suggest the effectiveness and feasibility
of computer-assisted CBT when delivered in commu-
nity mental health centers, which is where many chil-
dren are treated. Response and remission rates (61.2
and 55.1%) were similar to those demonstrated with
in-person treatment.[17] Gains among treatment respon-
ders were maintained at a 1-month follow-up assess-
ment. Notably, this study represents the second in-
stance of demonstrated treatment effectiveness with the
added strength of being conducted by an independent
research group in three geographically distributed com-
munity mental health settings. As such, Camp Cope-A-
Lot meets criteria as a “probably efficacious” treatment.
Like Khanna and Kendall,[27] therapists demonstrated
excellent treatment fidelity during in-person sessions,
which is impressive given the relatively short duration
of training and limited experience of clinicians with
CBT. Because the initial six sessions are delivered by
computer, while the other half guides the therapist
in exposure implementation, treatment integrity may
be enhanced relative to non-computer-assisted CBT
protocols, which was evidenced in [27]. Yet, there was
no detriment to treatment alliance with children and
their parents describing excellent therapeutic alliance.
Indeed, therapists noted rapid uptake of the treatment
protocol despite having little training in CBT other than
the initial workshop.[62] Parents and children also de-
scribed high intervention satisfaction, which was similar
to [27]. Parents and children appreciated the standardized
yet technologically oriented nature of treatment.[62]
However, our preliminary experience with this popu-
lation indicated that many families did not have easily
accessible internet service[63]; thus, we chose to have
children complete the initial six sessions at the treatment
facility rather than at home without therapist assistance.
Collectively, these data suggest that therapists within
Depression and Anxiety
850 Storch et al.
TABLE 3. Comparisons at posttest and followup for the computer-assisted CBT subsample
Posttest Followup
Measure nMean SD Mean SD Paired t-test Effect size d
Primary outcomes
PARS-Severity 24 7.9 3.8 7.0 3.5 1.02 0.25
CGI-Severity 24 2.0 0.7 1.8 0.5 1.45 0.27
ADIS CSR of primary anxiety diagnosis 24 2.3 1.1 1.8 1.2 1.63 0.43
Secondary outcomes
CDI 23 4.4 5.0 7.6 10.6 1.72 0.34
CBCL-Internal 24 7.5 5.6 4.5 3.9 3.57** 0.56
CBCL-External 24 5.0 6.8 4.3 6.0 0.99 0.13
CIS (parent) 24 5.8 8.6 6.7 6.6 0.75 0.09
CAIS (child) 22 10.4 11.0 10.4 11.8 0.06 0.01
CAIS (parent) 24 8.0 8.1 7.1 6.6 0.76 0.11
MASC 22 45.3 18.3 41.4 18.2 1.55 0.30
PARS, Pediatric Anxiety Rating Scale; CGI-Severity, Clinical Global Impressions-Severity; ADIS, Anxiety Disorder Interview Schedule; CSR,
Clinical Severity Rating; CDI, Children’s Depression Inventory; CBCL, Child Behavior Checklist; CIS, Columbia Impairment Scale; CAIS,
Childhood Anxiety Impact Scale; MASC, Multidimensional Anxiety Scale for Children.
P<.05, ∗∗P<.01, ∗∗∗ P<.001.
The effect size dsignifies the difference in scores between posttest and followup.
community mental health centers can be trained to
effectively deliver computer-assisted CBT.
We did not identify group differences in child-
reported secondary outcomes (e.g., anxiety-related im-
pairment and depressive symptoms). Possible expla-
nations include the following: (i) children reported
relatively low baseline levels of functional impair-
ment/depressive symptoms; (ii) computer-assisted CBT
focused primarily on anxiety symptoms and does not
yield significant effects on depressive symptoms; and/or
(iii) variability in child reports of symptoms, especially
when considering that parent reports of general and
anxiety-related impairment and parent-rated child inter-
nalizing/externalizing symptoms demonstrated signifi-
cant improvements.
Several study limitations should be noted. First,
though participants were recruited from three geograph-
ically diverse clinics throughout Florida, the majority
of the sample was Caucasian. Second, though the TAU
condition allowed participants to seek treatment, only
55.3% received active intervention, and such interven-
tion may not have conformed to evidence-based stan-
dards. Third, though comorbid mental health condi-
tions were assessed, environmental and home stressors
(e.g., changing schools, family dysfunction, and trauma
history) were not, which may have impacted on treat-
ment outcomes. Fourth, conclusions about the efficacy
of computer-assisted CBT relative to standard CBT can-
not be drawn based on the present study design. We
highlight the need for further research to determine if
computer-assisted CBT improves outcomes or imple-
mentation success relative to standard CBT. Fifth, the
initial six visits were held at the treatment facility versus
in home, limiting our ability to evaluate the potential for
time saved. Lastly, the 1-month follow-up duration was
not sufficient to evaluate long-term treatment mainte-
nance.
Within these limitations, these data speak of the mer-
its of a computer-assisted CBT protocol when used in
community mental health centers for treating anxious
youth. Computer-assisted programs for pediatric anxiety
may provide a platform to rapidly increase the dissemi-
nation of evidence-based practices in community-based
settings. Indeed, therapists and their administrators were
enthusiastic about the program content and efficacy, al-
though the latter did acknowledge the need for increased
technological support and concerns about reduced third-
party billing if half of the sessions occurred outside of the
clinic.[62] Similar to our pilot work[63] and other stud-
ies on computer-assisted treatment,[27,31] children and
parents were highly satisfied with the computer-assisted
treatment. In sum, the current study on computer-
assisted therapy by community therapists suggests that
Camp Cope-A-Lot can be feasibly implemented with
high treatment fidelity and therapeutic alliance result-
ing in significant improvements in anxiety and related
impairment in anxious children.
Acknowledgments. This work was supported by a
grant to the first author from the Agency for Healthcare
Research and Quality. The content is solely the respon-
sibility of the authors and does not represent the offi-
cial views of the Agency for Healthcare Research and
Quality.
Dr. Storch has received grant funding in the last 2
years from the National Institutes of Health, Agency for
Healthcare Research and Quality, All Children’s Hospi-
tal Research Foundation, International OCD Founda-
tion, and Ortho McNeil Scientific Affairs. He receives
textbook honorarium from Springer publishers, Amer-
ican Psychological Association, Wiley, and Lawrence
Erlbaum. Dr. Storch is the Clinical Director for Rogers
Depression and Anxiety
Research Article: Computer-assisted CBT 851
Behavioral Health – Tampa. He is a consultant for
Prophase and is on the Speaker’s Bureau and Scientific
Advisory Board for the International OCD Foundation.
Dr. Salloum has received grant funding in the last 2 years
from the National Institutes of Health, Eckerd Child
Welfare, and Crisis Center of Tampa Bay. She has re-
ceived royalties from Taylor and Francis and Centering
Corporation. King, Crawford, McBride, and Dr. Andel
have nothing to disclose. Dr. Lewin has received grant
funding in the last 2 years from the USF Research Foun-
dation, All Children’s Hospital Research Foundation,
and International OCD Foundation. He receives book
royalties from Springer. He has received travel support
from the Tourette Syndrome Association and Rogers
Memorial Hospital.
The contributions of Tyne Pierce, Amanda Krucke,
Christin Cooper, Wendy Kubar, Stephanie Dobbs,
and April Lott at Directions for Living in Largo,
Florida; Ashley Holden, Elise Ward, Sonya Hernan-
dez, Bhagirathy Sahasranaman, Nathalie Miniscalco,
and Pamela Galan at Henderson Behavioral Health in Ft.
Lauderdale, Florida; Tanya White, Lori Olsen, Shan-
non Massingale, Ruqayyah Gaber, John Bilbrey, Carol
Clark, Shaun Dahle, Ed Mobley, and Larry Williams
at Lakeview Center in Pensacola, Florida; Michael
Sulkowski, Elysse Arnold, Alessandro de Nadai, Joshua
Nadeau, Anna Jones, Brittany Kugler, Joseph McGuire,
Tanya Murphy, Danielle Ung, Jennifer Park, Marie
McPherson, and Robert Constantine at the University of
South Florida; Nick Dewan of BayCare Health System;
and Muniya Khanna at the University of Pennsylvania
are gratefully acknowledged.
REFERENCES
1. Anderson JC, Williams S, McGee R, Silva PA. DSM-III disorders
in preadolescent children. Prevalence in a large sample from the
general population. Arch Gen Psychiatry 1987;44(1):69–76.
2. Benjamin RS, Costello EJ, Warren M. Anxiety disorders in a pe-
diatric sample. J Anxiety Disord 1990;4(4):293–316.
3. Costello EJ, Egger HL, Angold A. The developmental epidemiol-
ogy of anxiety disorders: phenomenology, prevalence, and comor-
bidity. Child Adolesc Psychiatr Clin N Am 2005;14(4):631–648.
4. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Preva-
lence and development of psychiatric disorders in childhood and
adolescence. Arch Gen Psychiatry 2003;60(8):837–844.
5. Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a
neglected population: prevalence of anxiety disorders in pre-
adolescent children. Clin Psychol Rev 2006;26(7):817–833.
6. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz
DS. Prevalence and treatment of mental disorders among US chil-
dren in the 2001–2004 NHANES. Pediatrics 2010;125(1):75–81.
7. Chavira DA, Stein MB, Bailey K, Stein MT. Child anxi-
ety in primary care: prevalent but untreated. Depress Anxiety
2004;20(4):155–164.
8. Kendall PC, Compton SN, Walkup JT, et al. Clinical characteris-
tics of anxiety disordered youth. J Anxiety Disord 2010;24(3):360–
365.
9. Woodward LJ, Fergusson DM. Life course outcomes of young
people with anxiety disorders in adolescence. J Am Acad Child
Adolesc Psychiatry 2001;40(9):1086–1093.
10. Cummings CM, Caporino NE, Kendall PC. Comorbidity of anx-
iety and depression in children and adolescents: 20 years after.
Psychol Bull 2014;140(3):816–845.
11. Bittner A, Egger HL, Erkanli A, Costello EJ, Foley DL, Angold
A. What do childhood anxiety disorders predict? J Child Psychol
Psychiatry 2007;48(12):1174–1183.
12. Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child
anxiety treatment: outcomes in adolescence and impact on sub-
stance use and depression at 7.4-year follow-up. J Consult Clin
Psychol 2004;72(2):276–287.
13. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Wal-
ters EE. Lifetime prevalence and age-of-onset distributions of
DSM-IV disorders in the National Comorbidity Survey Repli-
cation. Arch Gen Psychiatry 2005;62(6):593–602.
14. Benjamin CL, Harrison JP, Settipani CA, Brodman DM, Kendall
PC. Anxiety and related outcomes in young adults 7 to 19 years
after receiving treatment for child anxiety. J Consult Clin Psychol
2013;81(5):865–876.
15. Reinblatt SP, Riddle MA. The pharmacological management
of childhood anxiety disorders: a review. Psychopharmacology
2007;191(1):67–86.
16. Silverman WK, Pina AA, Viswesvaran C. Evidence-based psy-
chosocial treatments for phobic and anxiety disorders in children
and adolescents. J Clin Child Adolesc Psychol 2008;37(1):105–
130.
17. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral
therapy, sertraline, or a combination in childhood anxiety. N Engl
J Med 2008;359(26):2753–2766.
18. Cartwright-Hatton S, Roberts C, Chitsabesan P, Fothergill C,
Harrington R. Systematic review of the efficacy of cognitive be-
haviour therapies for childhood and adolescent anxiety disorders.
Br J Clin Psychol 2004;43(4):421–436.
19. Shafran R, Clark DM, Fairburn CG, et al. Mind the gap: improv-
ing the dissemination of CBT. Behav Res Ther 2009;47:902–909.
20. Collins KA, Westra HA, Dozois DJA, Burns DD. Gaps in ac-
cessing treatment for anxiety and depression: challenges for the
delivery of care. Clin Psychol Rev 2004;24:583–616.
21. Elkins RM, McHugh RK, Santucci LC, Barlow DH. Improving
the transportability of CBT for internalizing disorders in children.
Clin Child Family Psychol Rev 14(2):161–173.
22. Kendall PC, Suveg C, Kingery JN. Facilitating the dissemina-
tion and application of cognitive-behavioral therapy for anxiety in
youth. J Cogn Psychother 2006;20(3):243–245.
23. Amir N, Taylor CT. Combining computerized home-based treat-
ments for generalized anxiety disorder: an attention modifica-
tion program and cognitive behavioral therapy. Behav Ther
2012;43(3):546–559.
24. Kendall PC, Khanna MS, Edson A, Cummings C, Harris MS.
Computers and psychosocial treatment for child anxiety: recent
advances and ongoing efforts. Depress Anxiety 2011;28(1):58–66.
25. Lack CW, Storch EA. The use of computers in the assessment and
treatment of obsessive–compulsive disorder. Comput Hum Behav
2008;24(3):917–929.
26. Khanna MS, Kendall PC. Computer-assisted CBT for child anx-
iety: the coping cat CD-ROM. Cogn Behav Pract 2008;15:159–
165.
27. Khanna MS, Kendall PC. Computer-assisted cognitive behavioral
therapy for child anxiety: results of a randomized clinical trial. J
Consult Clin Psychol 2010;78(5):737–745.
28. Spence SH, Donovan CL, March S, et al. A randomized controlled
trial of online versus clinic-based CBT for adolescent anxiety. J
Consult Clin Psychol 2011;79(5):629–642.
Depression and Anxiety
852 Storch et al.
29. Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Com-
puter therapy for the anxiety and depressive disorders is effective,
acceptable and practical health care: a meta-analysis. PLoS One
5(10):1–6.
30. March S, Spence SH, Donovan CL. The efficacy of an internet-
based cognitive-behavioral therapy intervention for child anxiety
disorders. J Pediatr Psychol 2009;34(5):474–487.
31. Spence SH, Holmes JM, March S, Lipp OV. The feasibility and
outcome of clinic plus internet delivery of cognitive-behavior ther-
apy for childhood anxiety. J Consult Clin Psychol 2006;74(3):614–
621.
32. O’Kearney R, Kang K, Christensen H, Griffiths K. A controlled
trial of a school-based Internet program for reducing depressive
symptoms in adolescent girls. Depress Anxiety 2009;26(1):65–
72.
33. van der Zanden R, Kramer J, Gerrits R, Cuijpers P. Effectiveness
of an online group course for depression in adolescents and young
adults: a randomized trial. J Med Internet Res 2012;14(3):e86.
34. Cuijpers P, Donker T, van Straten A, Li J, Andersson G. Is guided
self-help as effective as face-to-face psychotherapy for depres-
sion and anxiety disorders? A systematic review and meta-analysis
of comparative outcome studies. Psychol Med 2010;40(12):1943–
1957.
35. Blocher JB, Fujikawa M, Sung C, Jackson DC, Jones JE.
Computer-assisted cognitive behavioral therapy for children with
epilepsy and anxiety: a pilot study. Epilepsy Behav 2013;27(1):70–
76.
36. Vigerland S, Thulin U, Lj´
otsso B, et al. Internet-delivered CBT
for children with specific phobia: a pilot study. Cogn Behav Ther
2013;42(4):303–314.
37. Abeles P, Verduyn C, Robinson A, Smith P, Yule W, Proudfoot
J. Computerized CBT for adolescent depression (“Stressbusters”)
and its initial evaluation through an extended case series. Behav
Cogn Psychother 2009;37(2):151–165.
38. Chambless DL, Hollon SD. Defining empirically supported ther-
apies. J Consult Clin Psychol 1998;66(1):7–18.
39. Silverman WK, Albano AM. The Anxiety Disorders Interview
Schedule for DSM-IV-Child and Parent Versions. San Antonio,
TX: Graywinds Publications; 1996.
40. RUPP. The pediatric anxiety rating scale (PARS): development
and psychometric properties. J Am Acad Child Adolesc Psychiatry
2002;41(9):1061–1069.
41. Caporino NE, Brodman DM, Kendall PC, et al. Defining treat-
ment response and remission in child anxiety: signal detection
analysis using the pediatric anxiety rating scale. J Am Acad Child
Adolesc Psychiatry 2013;52(1):57–67.
42. Wilkinson GS, Robertson G. WRAT4: Wide Range Achievement
Test Professional Manual. 4th ed. Lutz, FL: Psychological Assess-
ment Resources; 2006.
43. Kendall PC, Hedtke KA. Coping Cat Workbook. 3rd ed. Ard-
more, PA: Workbook Publishing; 2006.
44. Kendall PC, Hedtke KA. Cognitive-Behavioral Therapy for Anx-
ious Children: Therapist Manual. 3rd ed. Ardmore, PA: Work-
book Publishing; 2006.
45. Lyneham HJ, Abbott MJ, Rapee RM. Interrater reliability of the
Anxiety Disorders Interview Schedule for DSM-IV: child and par-
ent version. J Am Acad Child Adolesc Psychiatry 2007;46(6):731–
736.
46. Guy W. Clinical global impressions. In: ECDEU Assessment
Manual for Psychopharmacology—Revised. Rockville, MD: Na-
tional Institute of Mental Health; 1976.
47. Horwitz SM, Hoagwood K, Stiffman AR, et al. Reliability of the
services assessment for children and adolescents. Psychiatr Serv
2001;52:1088–1094.
48. Achenbach T. Manual for the ASEBA School-Age Forms and Pro-
files. Burlington: University of Vermont; 2001.
49. Bird H, Andrews H, Schwab-Stone M, et al. Global measures of
impairment for epidemiologic and clinical use with children and
adolescents. Int J Methods Psychiatr Res 1996;6:295–307.
50. Langley AK, Bergman RL, McCracken J, Piacentini JC. Impair-
ment in childhood anxiety disorders: preliminary examination of
the child anxiety impact scale-parent version. J Child Adolesc Psy-
chopharmacol 2004;14(1):105–114.
51. Langley AK, Falk A, Peris T, et al. The child anxiety impact scale:
examining parent- and child-reported impairment in child anxiety
disorders. J Clin Child Adolesc Psychol 2014;43(4):579–591.
52. March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The
Multidimensional Anxiety Scale for Children (MASC): factor
structure, reliability, and validity. J Am Acad Child Adolesc Psy-
chiatry 1997;36(4):554–565.
53. Kovacs M. The Children’s Depression, Inventory (CDI). Psy-
chopharmacol Bull 1985;21(4):995–998.
54. Saylor CF, Finch AJ, Spirito A, Bennett B. The children’s depres-
sion inventory: a systematic evaluation of psychometric properties.
J Consult Clin Psychol 1984;52(6):955.
55. Timbremont B, Braet C, Dreessen L. Assessing depression
in youth: relation between the Children’s Depression Inven-
tory and a structured interview. J Clin Child Adolesc Psychol
2004;33(1):149–157.
56. Shirk S, Saiz C. The therapeutic alliance in child therapy: clini-
cal, empirical, and developmental perspectives. Dev Psychopathol
1992;4(4):713–728.
57. Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assess-
ment of client/patient satisfaction: development of a general scale.
Eval Program Plann 1979;2(3):197–207.
58. Copeland VC, Koeske G, Greeno CG. Child and mother client
satisfaction questionnaire scores regarding mental health ser-
vices: race, age, and gender correlates. Res Soc Work Pract
2004;14(6):434–442.
59. Littell RC, Milliken GA, Stroup WW, Wolfinger RD, Schaben-
berger O. SAS for Mixed Models. 2nd ed. Cary, NC: SAS Institute;
2006.
60. Hamer R, Simpson P. Last observation carried forward versus
mixed models in the analysis of psychiatric clinical trials. Am J
Psychiatry 2009;166(6):639–641.
61. Kazdin AE, Bass D. Power to detect differences between alterna-
tive treatments in comparative psychotherapy outcome research.
J Consult Clin Psychol 1989;57(1):138–147.
62. Salloum A, Crawford EA, Lewin AB, Storch EA. Consumers’ and
providers’ perceptions of utilizing a computer-assisted cognitive
behavioral therapy for childhood anxiety. Behav Cogn Psychother
2015;43(01):31–41.
63. CrawfordEA, Salloum A, Lewin AB, Andel R, Murphy TK, Storch
EA. A pilot study of computer-assisted cognitive behavioral ther-
apy for childhood anxiety in community mental health centers. J
Cogn Psychother 2013;27(3):221–234.
Depression and Anxiety
... If predefined outcomes could not be retrieved from published results, lead authors were contacted. This led to that additional data about remission for all ADs were added for three studies (Jolstedt et al., 2018;Storch et al., 2015;Vigerland et al., 2016). ...
... We used the 2 nd version of the Cochrane Risk of Bias (RoB) tool to evaluate RoB for each result across the following domains: (a) bias arising from the randomization process, (b) bias due to deviations from intended interventions, (c) bias due to missing outcome data, (d) bias in measurement of the outcome, (e) bias in selection of the reported results, and (f) overall bias (Sterne et al., 2019). An RoB rating of low, high, or some concerns was provided for each domain and the rating of overall bias was based on ratings in the first five domains. ...
... Nine studies fulfilled PICO criteria (Jolstedt et al., 2018;Khanna & Kendall, 2010;March, Spence, & Donovan, 2009;Spence et al., 2006Spence et al., , 2011Spence, Donovan, March, Kenardy, & Hearn, 2017;Storch et al., 2015;Vigerland et al., 2016;Waite, Marshall, & Creswell, 2019). One study (Spence et al., 2017) tested two types of tCBT (generic vs. disorder-specific for social AD) and found no statistically significant differences between them; the two estimates were pooled for the purposes of the present study. ...
Article
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Background: The efficacy of technology-delivered cognitive-behavioral therapy (tCBT) for pediatric anxiety disorders (ADs) is uncertain as no meta-analysis has examined outcomes in trials that used structured diagnostic assessments at pre- and posttreatment. Methods: We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) of tCBT for pediatric ADs that included participants <18 years of age with a confirmed primary AD according to a structured diagnostic interview. Nine studies with 711 participants were included. Results: tCBT outperformed control conditions for remission for primary AD (37.9% vs. 10.2%; k = 9; OR = 4.73; p < .0001; I2 = 0%; moderate certainty), remission for all ADs (19.5% vs. 5.3%; k = 8; OR = 3.32; p < .0001; I2 = 0%; moderate certainty), clinician-rated functioning (k = 7; MD = -4.38; p < .001; I2 = 56.9%; low certainty), and caregiver-reported anxiety (k = 7; SMD = 0.27; p = .02; I2 = 41.4%; low certainty), but not for youth-reported anxiety (k = 9; SMD = 0.13; p = .12; I2 = 0%; low certainty). More severe pretreatment anxiety, a lower proportion of completed sessions, no face-to-face sessions, media recruitment, and a larger proportion of females were associated with lower remission rates for primary AD. Conclusions: tCBT has a moderate effect on remission for pediatric ADs and clinician-rated functioning, a small effect on caregiver-reported anxiety, and no statistically significant effect on youth-reported anxiety. The certainty of these estimates is low to moderate. Remission rates vary substantially across trials and several factors that may influence remission were identified. Future research should examine for whom tCBT is most appropriate and what care to offer the large proportion that does not remit. Future RCTs should consider contrasting tCBT with partial tCBT (e.g., including therapist-led exposure) and/or face-to-face CBT.
... The remaining articles reviewed had less thorough descriptions of their conceptualization of caregiver satisfaction, but a few commonalities among studies emerged. Five studies conceptualized caregiver satisfaction as a measure of engagement or acceptability of a mental health intervention [9,38,52,78,89,90]. Three studies explained their measurement of satisfaction as a measurement of caregivers' perceptions of treatment effectiveness [41,53,75]. ...
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Nearly four decades ago, Unclaimed Children documented the gaps in the United States between mental health programs and caregivers’ perspectives about those services for their children. This absence of attention to parent or caregiver perspectives, including their satisfaction with these services, was a key finding of the report, which detailed system failure in caring for youth with mental health needs. Since then, the focus on caregiver satisfaction with children’s mental health services has been largely overlooked in research, and when examined has been mostly included as an indicator of the feasibility of program implementation. In striking contrast, overall healthcare system reforms have highlighted the importance of improving consumer’s direct experience of care. However, caregiver satisfaction remains largely disconnected to these overall health system reforms, even as reforms focus increasingly on value-based, coordinated and integrated care. In this paper, we review literature from 2010 to 2020, revisit the measurement of caregiver satisfaction, identify how and when it is being measured, and delineate a research agenda to both realign it with health system improvements, refine its focus on expectancies and appropriateness, and root it more firmly in the principles of user experience (UX) and human-centered design (HCD).
... Most studies examining the outcomes of CBT for pediatric anxiety are conducted in specialized treatment environments with narrowly selected participant groups (efficacy research), so it is important to establish how well CBT performs in more "real world" treatment environments such as community clinics (effectiveness research). A number of studies have supported CBT as an effective treatment option for youth anxiety, whether delivered in a group, individual, or computerassisted treatment format (Djurhuus & Bikic, 2019;Storch et al., 2015;Villabø et al., 2018;Wergeland et al., 2014). ...
Chapter
This chapter focuses on the efficacy of cognitive behavioral therapy (CBT) in the treatment of pediatric anxiety disorders. The chapter will first outline the presentation of anxiety disorders in youth, which are among the most common mental disorders in pediatric populations. It will then describe the core components of CBT, which has been demonstrated to be an efficacious treatment for youth anxiety, with lower dropout and fewer adverse events compared to other treatment options. Key supporting evidence will then be reviewed, along with important treatment considerations such as treatment format, treatment intensity, and comorbidity. CBT can also be applied to many neurodevelopmental conditions and challenges. Given the potential for chronic mental illness and associated risk of adverse outcomes in adulthood, it is imperative that pediatric anxiety be properly diagnosed and treated.
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Introduction Childhood anxiety is common, causes significant functional impairment and may lead to psychosocial problems by adulthood. Although cognitive behavioural therapy (CBT) is effective for treating anxiety, its availability is limited by the lack of trained CBT therapists and easily accessible local services. To address the challenges in both recognition and treatment, this study combines systematic anxiety screening in the general population with a randomised controlled trial (RCT) on internet-assisted CBT (ICBT) with telephone coaching. Child, family and intervention-related factors are studied as possible predictors or moderators, together with the COVID-19 pandemic. Methods and analysis The study is an open two-parallel group RCT, stratified by sex, that compares ICBT with telephone coaching to an education control. Children aged 10–13 are screened at yearly school healthcare check-ups using five items from the Screen for Child Anxiety Related Disorders (SCARED) Questionnaire. The families of children who screen positive for anxiety are contacted to assess the family’s eligibility for the RCT. The inclusion criteria include scoring at least 22 points in the 41-item SCARED Questionnaire. The primary outcome is the SCARED child and parent reports. The secondary outcomes include the impact of anxiety, quality of life, comorbidity, peer relationships, perceptions of school, parental well-being and service use. Additional measures include demographics and life events, anxiety disorder diagnoses, as well as therapeutic partnerships, the use of the programme and general satisfaction among the intervention group. Ethics and dissemination The study has been approved by the research ethics board of the Hospital District of South West Finland and local authorities. Participation is voluntary and based on informed consent. The anonymity of the participants will be protected and the results will be published in a scientific journal and disseminated to healthcare professionals and the general public. Trial registration number ClinicalTrials.gov NCT03310489 , pre-results, initially released on 30 September 2017.
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Background: Cognitive behavior therapy (CBT) has been shown to be an effective treatment for specific phobia in youth, but not all affected seek or receive treatment. Internet-delivered CBT could be a way to increase the availability of empirically supported treatments. Aims: An open trial was conducted to evaluate Internet-delivered CBT for children with specific phobia. Method: Children (N = 30) aged 8-12, and their parents, with a principal diagnosis of specific phobia were recruited through media advertisement. Participants received six weeks of Internet-delivered CBT with therapist support. The treatment was aimed for the parents and the children, with the first part being only for the parents. The primary outcome measure was the Clinician Severity Rating (CSR), and secondary measures included clinician-rated global functioning and child- and parent-reported anxiety and quality of life. All assessments were made at pretreatment, posttreatment, and three-month follow-up. Results: At posttreatment, there were significant reductions on the CSR, with a large within-group effect size (Cohen's d = 1.0) and 35% of children no longer meeting criteria for specific phobia. Self-report measures from parents and children showed significant effects on anxiety, with small to moderate effect sizes. Effects were maintained at three-month follow-up. Conclusions: Results show that Internet-delivered CBT with therapist support for children with specific phobia has the potential to reduce symptom severity. Randomized controlled trials are needed to further evaluate this treatment format.
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This study used the Client Satisfaction Questionnaire (CSQ-8) to examine the level of consumer satisfaction with children’s (ages 8 to 17 years) outpatient mental health services. Analyses were completed using both individual satisfaction items and a summed scale score. The CSQ scale had satisfactory internal consistency reliability for both mothers (alpha = .96) and children (alpha = .93). Parents’ratings of satisfaction with their child’s treatment were not uniformly consistent with those of the child who was in treatment. Mothers’and children’s ratings were significantly, but only moderately, related. We also found that a child’s satisfaction with outpatient services, relative to that of the parent, may depend on the child’s gender, race, and age. These findings suggest that children’s satisfaction with mental health treatment was complexly determined and should not be inferred from their mothers’degree of satisfaction.
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The purpose of the current investigation was to examine the factor structure, reliability, and construct validity of both the Child and Parent version of the Child Anxiety Impact Scale (CAIS) using data obtained from the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008). The CAIS child and parent versions measure anxiety-related functional impairment in school, social, and family domains. Participants were 488 children ages 7 to 17 (M age = 10.7, SD = 2.8 years) enrolled as part of the CAMS study across 6 sites and their primary parent or caregiver. Families participated in a structured diagnostic interview and then completed the CAIS along with other measures. Confirmatory factor analysis revealed that the a priori three-factor structure (school, social, and home/family) for the CAIS parent- and CAIS child-report was a reasonable fit, with a comparative fit index of.88 and root mean square error of approximation of.05. Internal consistency was very good for total score and subscales of both versions of the scale (Cronbach's α =.70-.90). The CAIS total scores demonstrated good construct validity, showing predicted significant correlations with the Child Behavior Checklist (CBCL) Internalizing Scale, the Multidimensional Anxiety Scale for Children (MASC) and Screen for Child Anxiety Related Emotional Disorders (SCARED) Total Scores, the Pediatric Anxiety Rating Scale, and the Children's Global Assessment Scale. In addition, CAIS Social and School subscales were significantly related to similar subscales on the CBCL, SCARED, and MASC. The results provide support that the CAIS is a reliable and valid measure for the assessment of the impact of anxiety on child and adolescent functioning.