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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. 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. 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. 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.
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A Randomized Controlled Trial of Online Versus Clinic-Based CBT for
Adolescent Anxiety
Susan H. Spence, Caroline L. Donovan, and
Sonja March
Griffith University
Amanda Gamble
Macquarie University
Renee E. Anderson
University of Queensland
Samantha Prosser
Griffith University
Justin Kenardy
University of Queensland
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: Partic-
ipants 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.
Keywords: adolescent, anxiety, cognitive behavior therapy, computer, online
It has been well established that anxiety disorders in children
can be treated efficaciously with cognitive behavior therapy
(CBT), with average remission rates of between 56% and 67% at
post-treatment (Cartwright-Hatton, Roberts, Chitsabesan, Fother-
gill, & Harrington, 2004; James, Soler, & Weatherall, 2008; Sil-
verman, Pina, & Viswesvaran, 2008). An issue of concern, how-
ever, is that only around 25% of clinically anxious young people
receive professional help (Essau, Conradt, & Petermann, 2000;
Keller et al., 1992). There are various reasons for this, including
the failure to recognize that there is a problem, lack of knowledge
about the availability of treatment, long waiting lists, lack of
trained therapists, high costs of therapy, perceived stigma of at-
tending a mental health clinic, and time constraints on the family
(Stallard, Udwin, Goddard, & Hibbert, 2007). Clearly, there is a
need for alternative modes of treatment delivery that increase the
chance that young people and their parents will seek help and
participate in treatment.
Computer-based CBT has been proposed as one way of increas-
ing access to therapy for mental health problems and has now been
evaluated for a number of psychological disorders, including anx-
iety, with very promising results (Reger & Gahm, 2009). To date,
studies have predominantly involved adults, with research into the
use of such technologies with children and adolescents still in its
infancy. Computer-based therapies may be particularly appropriate
for young people. They can be accessed at any time and offer a
This article was published Online First July 11, 2011.
Susan H. Spence, Caroline L. Donovan, Sonja March, and Samantha
Prosser, School of Psychology, Griffith University, Brisbane, Queensland,
Australia; Amanda Gamble, Department of Psychology, Macquarie Uni-
versity, Sydney, New South Wales, Australia; Renee E. Anderson, School
of Psychology, University of Queensland, Herston, Queensland, Australia;
Justin Kenardy, School of Psychology, University of Queensland, and
Centre of National Research on Disability and Rehabilitation, School of
Medicine, University of Queensland.
We would like to the thank the National Health and Medical Research
Council for funding this research.
Correspondence concerning this article should be addressed to Caroline
L. Donovan, School of Psychology, Griffith University, Brisbane, Queens-
land, Australia. E-mail: c.donovan@griffith.edu.au
Journal of Consulting and Clinical Psychology © 2011 American Psychological Association
2011, Vol. 79, No. 5, 629– 642 0022-006X/11/$12.00 DOI: 10.1037/a0024512
629
sense of privacy and confidentiality that is highly valued by
adolescents (James, 2007; Stallard, Velleman, & Richardson,
2010). Indeed, adolescents demonstrate a preference for text-based
(e-mail) or online counseling over talk-based (telephone) counsel-
ing (King, Bambling, Reid, & Thomas, 2006), and a large propor-
tion report using computers to search the web for information
relating to worries, unhappiness, or other problems (Stallard et al.,
2010). Finally, communication applications on the Internet, such
as e-mail, instant messaging, blogs, and chat rooms, have become
a very important and familiar component of the lives of many
adolescents (Subrahmanyam & Lin, 2007). However, given that it
is frequently parents who initiate treatment for their child, it is also
important that parents find computer-based therapy to be a credible
and acceptable form of treatment if it is to become widely adopted.
To date, there appear to be only three published randomized
controlled trials evaluating Internet-based treatments for childhood
anxiety, none of which have involved adolescents (Khanna &
Kendall, 2010; March, Spence, & Donovan, 2009; Spence, Hol-
mes, March, & Lipp, 2006). Spence, Holmes, March, and Lipp
(2006) compared clinic-based group CBT, the same treatment
partially delivered via the Internet, and a wait list control with
anxious children. The clinic and the combined clinic-Internet con-
ditions showed significantly greater reductions in anxiety symp-
toms from pre- to post-treatment than the wait list, with improve-
ments being maintained at 12-month follow-up. Subsequently,
March et al. (2009) examined the efficacy of the same program
when delivered fully online, with only minimal therapist contact
by e-mail and phone, in comparison to a wait list control. Children
in the Internet condition showed small but significant reductions in
clinician-rated anxiety severity, global assessment of functioning,
and parent self-report measures of child anxiety compared with the
wait list at 12-week assessment. By 6-month follow-up, 75% of
children in the Internet condition no longer met criteria for their
anxiety disorder. Recently, Khanna and Kendall (2010) reported a
small-scale randomized controlled trial comparing computer as-
sisted treatment for 7–13-year-old anxious children with individ-
ual, clinic-based CBT. Both treatments were associated with sig-
nificantly greater reductions in anxiety than an attention placebo
control condition. Improvements for both treatments continued
over the 3-month follow-up period, with no difference in outcome.
Research relating to the evaluation of online or computer as-
sisted CBT has, to date, been focused on younger children, rather
than adolescents. Given the potential value of online treatment for
adolescent anxiety problems, it is particularly important to deter-
mine its efficacy. The current study builds on previous research by
comparing the efficacy of online delivery of CBT for clinically
anxious adolescents, with clinic-based treatment and a wait list
control group. It also examines both youth and parental percep-
tions of credibility and satisfaction with the online therapy ap-
proach. Given that both parents and the young person are typically
involved in the decision to seek and participate in treatment, it is
important that both parties regard online CBT as a credible form of
therapy.
It was hypothesized that both clinic and Internet delivery of
CBT at the 12-week post-therapy assessment point would be
associated with greater reductions in anxiety than the wait list and
that post-treatment improvements would be maintained or en-
hanced at follow-up. It was further hypothesized that Internet-
delivered CBT would be perceived as a credible form of therapy
by parents and adolescents, with a high level of treatment satis-
faction reported by both.
Method
Participants
Participants were 115 adolescents (47 male, 68 female) with
clinical levels of anxiety, aged from 12 to 18 years (M13.98,
SD 1.63), and at least one of their parents. The majority of
adolescents were born in Australia (91%), with the remainder born
in Europe, New Zealand, Asia, South Africa, and the United States
of America. Seventy-eight percent of adolescents lived with both
biological parents, 14% lived with their mother, 7% lived with
their mother and step-father, and 1% lived with their father. The
sample was relatively high in socioeconomic status, with 47% of
households having an annual income greater than AUD $100,000.
In general, parents were relatively well educated, with 46% of
fathers and 51% of mothers having completed a university educa-
tion.
In terms of a primary diagnosis, 48% of adolescents had gen-
eralized anxiety disorder (GAD), 35% had social phobia (SoP),
13% had separation anxiety disorder (SAD), and 4% had a specific
phobia (SP). Overall, 84% of the sample also had a comorbid
anxiety disorder at a level of clinical significance. The mean
number of anxiety diagnoses for adolescents prior to beginning
treatment was 2.67 (SD 1.31). A proportion of adolescents also
met criteria for a comorbid disorder other than anxiety (overall
18%), including depression (2.6%), dysthymic disorder (6%), at-
tention-deficit/hyperactivity disorder (9.6%), and oppositional de-
fiant disorder (1.7%).
To be included in the study, adolescents were required to have
a primary diagnosis of SAD, SoP, GAD, or SP; be aged between
12 and 18 years; have access to a computer and the Internet at
home; and be able to read and write English at an age-appropriate
level. While adolescents with a primary diagnosis of panic disorder
(PD), obsessive compulsive disorder (OCD), or posttraumatic
stress disorder (PTSD) were not eligible for inclusion in the study,
these disorders were permissible as secondary diagnoses if the
level of severity was assessed as insufficient to interfere with
treatment integrity for the primary disorder. We did not accept
these disorders as primary presenting problems, as the intervention
did not include elements that are normally included in the treat-
ment of these particular problems, such as response prevention (for
OCD), controlled breathing (for PD), or imaginal exposure (for
PTSD).
For ethical reasons, adolescents with a mood disturbance rated
“moderately disturbing” or greater (severity rating of 6 or higher
on the Anxiety Disorders Interview Schedule—Child Version;
Silverman & Albano, 1996) were excluded from the study and
referred elsewhere for treatment for their mood disorder. Those
with a pervasive developmental disorder, learning disorder, signif-
icant behavioral disorder, substance abuse, suicidal ideation, or
current self-harm were excluded from the study.
Of the 288 families who approached the study, 30 did not meet
broad inclusion criteria at the telephone screen stage (e.g., outside
age range, non-anxiety-related difficulties, location, lack of Inter-
net access), and 258 were invited to provide informed consent and
participate in the more detailed assessment to determine eligibility.
630 SPENCE ET AL.
At this point families were provided with more detailed informa-
tion about the study, the nature of the random allocation, and the
need for willingness and capacity to participate in any of the
conditions if allocated. Sixty-six families declined or failed to
complete the detailed online questionnaires and diagnostic base-
line assessment. Detailed information about reasons for nonpar-
ticipation is not available as families had not yet provided in-
formed consent to participate in the study or completed baseline
assessments. However, according to the interviewers’ reports, rea-
sons typically included perceived lack of time for therapy partic-
ipation over the required period, transport difficulties if allocated
to the clinic condition, unwillingness to agree to random allocation
due to a preference for either Internet or clinic therapy, unwilling-
ness to be on a wait list, lack of interest in a CBT approach, and
preference for pharmacological treatment from a general practitio-
ner or psychiatrist. This left 192 families who were willing and
able to participate in the study. Following baseline assessment, a
further 72 were then excluded on the basis of diagnostic exclusion
criteria described above, and five families declined further partic-
ipation for personal reasons. The remaining 115 families met all
inclusion criteria, provided informed consent, and were randomly
allocated to an experimental condition. The flow through and
retention of participants at each phase of the study are summarized
in Figure 1.
Measures
For ease of interpretation, measures used in this study were
grouped into primary and secondary outcome measures. These
measures are described below.
Primary outcome measures (diagnostic status and severity).
Anxiety Disorders Interview Schedule for DSM–IV: Child and
Parent Versions. Diagnostic status was assessed using the Anx-
iety Disorders Interview Schedule—Child and Parent Versions
(ADIS–C/P; Silverman & Albano, 1996), administered over the
telephone. Administration of the ADIS–C/P over the telephone has
been demonstrated to have comparable validity to in-person ad-
ministration and also has high inter-rater reliability (Cobham,
Dadds, & Spence, 1999; Lyneham & Rapee, 2005). Assessors
independent of the study and blind to treatment condition con-
ducted the assessments. Assessors were psychologists with a min-
imum of 8 hr of training in the use of the interview schedule and
who received ongoing weekly supervision. A combined report was
formed by the interviewer to reflect the responses provided by both
the adolescent and the parent. Each diagnosis was assigned a
clinician severity rating (CSR) from 0 to 8 (0 absent,8very
severely disturbing or disabling), with scores of 4 and above
representative of clinical levels of impairment. When instances
occurred in which there were two or more diagnoses with the same
severity rating, decisions regarding which diagnosis would be
taken as primary were determined by the interviewing clinician
based on a fine-grained analysis of the degree of impairment and
severity of the presenting symptoms for each disorder, based on
parent- and child-report on the ADIS. Prior to treatment, the mean
clinical severity rating of the primary presenting anxiety disorder
for the overall sample was 6.00 (SD 0.87), indicative of “mark-
edly disturbing/disabling” levels of anxiety.
A random sample of 15% of adolescent and parent interviews
was used to determine diagnostic reliability. There was high inter-
assessor agreement, with a kappa of 0.94 for the primary diagnosis
and a correlation of .92 for the severity ratings between the initial
interviewer and second, independent assessor.
The Children’s Global Assessment Scale. The blind assessor
also completed the Children’s Global Assessment Scale (CGAS;
Shaffer et al., 1983). Scores ranging between 81 and 100 on the
CGAS represent normal levels of functioning, scores of 61– 80
indicate slight disability, moderate disability is represented by
scores between 41 and 60, and scores of 1– 40 indicate serious
disability (Shaffer et al., 1983). The CGAS has demonstrated good
inter-rater reliability (r.84) and test–retest reliability (r.85;
Dyrborg et al., 2000; Rey, Starling, Wever, Dossetor, & Plapp,
1995; Shaffer et al., 1983). Inter-assessor reliability for the CGAS
in the present study was .91 between the initial interviewer and the
independent assessor.
Secondary outcome measures (child- and parent-reported
questionnaires).
Anxiety symptom questionnaires. The Spence Children’s
Anxiety Scale (SCAS; Spence, 1998, 1999) Child (SCAS–C) and
Parent (SCAS–P) versions were employed to measure level of
adolescent anxiety. The SCAS scales include 38 items reflecting
symptoms of anxiety scored for frequency of occurrence (0
never to 3 always) and include six subscales measuring panic/
agoraphobia, social phobia, separation anxiety, generalized anxi-
ety, obsessions/compulsions, and fear of physical injury. The
SCAS–C and SCAS–P have sound psychometric properties, with
internal consistency reported at .89 for the total parent anxiety
score and .92 for the total child score (Muris, Schmidt, & Merck-
elbach, 2000; Nauta et al., 2004; Spence, 1998; Spence, Barrett, &
Turner, 2003).
Adolescent internalizing symptoms were measured using the
Internalizing subscales of the Child Behavior Checklist (CBCL;
Achenbach & Rescorla, 2001) and the Youth Self-Report (YSR;
Achenbach & Rescorla, 2001). Responses are rated on a 3-point
scale (0 never,1sometimes,2often), with higher scores
indicating greater levels of symptoms. The psychometric proper-
ties of both questionnaires have been well established (Achenbach
& Rescorla, 2001).
Treatment expectancy and credibility ratings. Treatment ex-
pectancy and credibility ratings were collected from adolescents
and parents following completion of the first treatment session.
The measure used in the current study was adapted from a measure
originally developed by Spence, Holmes, March, and Lipp (2006)
and amended to suit the online intervention. Consisting of five
items relating to expectations about the intervention (e.g., “How
much do you expect this program will help you beat your fears and
worries?”), the scale asked participants to rate their agreement with
each item on a 10-point scale (0 not at all,9completely).
Items were summed to form a total score, with higher scores
representing greater treatment outcome expectancy and perceived
credibility of the program.
Treatment satisfaction. At the 12-week assessment point,
adolescents and parents were asked to rate their satisfaction with
the intervention. The satisfaction scale has been previously de-
scribed by Spence and colleagues (Spence, Holmes, March, &
Lipp, 2006), who adapted the questionnaire from an 11-point scale
originally developed by Cobham et al. (1999). The questionnaire
consisted of eight items measured on a 5-point scale (1 not at
all,5very much). Scores were averaged to provide a mean
631
ONLINE CBT FOR ADOLESCENT ANXIETY
satisfaction score. Higher scores were indicative of a higher level
of satisfaction with the intervention.
Procedure
Data collection occurred across three sites from 2006 –2008:
The University of Queensland and Griffith University in Brisbane,
Australia, and Macquarie University in Sydney, Australia. Recruit-
ment, assessment, intervention, and follow-up procedures were
identical across the three sites. Participants were recruited through
advertisements in school newsletters, newspaper articles, televi-
sion and radio interviews, and through referral from school guid-
ance officers, general practitioners, and other mental health pro-
fessionals. An initial screening interview was conducted over the
telephone with parents of potential participants. Adolescents who
met broad inclusion criteria, together with at least one of their
parents, were then provided with information about the study and
Figure 1. CONSORT diagram of participants’ progress through each phase of the study. NET Internet-based
treatment; CLIN clinic-based treatment; WLC wait list control.
632 SPENCE ET AL.
asked to provide online, informed consent, to complete a battery of
online questionnaires, and to participate in diagnostic interviews.
The ADIS–C/P was then conducted via the telephone with ado-
lescents and parents to determine the primary diagnosis and level
of anxiety severity and to confirm eligibility criteria.
Families who met all inclusion criteria following diagnostic
assessment and who provided informed consent were randomly
assigned to one of three treatment conditions: clinic-based treat-
ment (CLIN), Internet-based treatment (NET), or a wait list control
condition (WLC). Order of random assignment was established
ahead of time through a computer program and implemented by a
research team member not involved in the recruitment process.
Fewer young people were assigned to the WLC condition, as a
large effect size between the WLC and treatment conditions was
expected and fewer numbers were required for adequate power in
statistical analyses. Recruitment was limited to Brisbane and Syd-
ney metropolitan areas to allow for random allocation of partici-
pants to either CLIN or NET conditions.
The online questionnaires and telephone diagnostic interviews
were re-administered approximately 12 weeks after baseline by
which time it was predicted that participants should have com-
pleted the 10 weekly therapy sessions. After this point, the WLC
participants were offered the online intervention and ceased to be
part of the study. Interviews and questionnaire packages were
re-administered at 6- and 12-month follow-up for NET and CLIN
conditions. This study was conducted in accordance with The
University of Queensland, Macquarie University, and Griffith Uni-
versity Human Ethics Committees.
Content of the Interventions
Internet-based treatment (NET). Participants in the
Internet-based treatment condition completed BRAVE for Teen-
agers—ONLINE (Spence, Holmes, & Donovan, 2006). A detailed
description of the BRAVE interventions has been provided else-
where (March et al., 2009; Spence et al., 2008), and therefore the
following contains only a brief overview. The intervention is based
on theoretical and empirical research relating to the psychosocial
determinants of child anxiety (Dadds & Roth, 2001; Rapee &
Spence, 2004; Silverman & Treffers, 2001) and evidence-based,
cognitive behavioral interventions (Barrett, 1998; Rapee, Wignall,
Hudson, & Schniering, 2000; Spence, Donovan, & Brechman-
Toussaint, 2000).
The content, length, and number of session activities in the
Internet program are designed to replicate those of the clinic-based
version of the program. It targets four types of anxiety: social
anxiety, generalized anxiety, separation anxiety, and specific pho-
bias. Sessions incorporate standard CBT anxiety management
strategies including psychoeducation, relaxation training, recogni-
tion of the physiological symptoms of anxiety, cognitive strategies
of coping self-talk and cognitive restructuring, graded exposure,
problem solving, and self-reinforcement. Parent sessions focus on
the acquisition of the above-mentioned CBT techniques, in addi-
tion to parenting strategies to empower parents to help their
adolescents to implement anxiety management skills and to effec-
tively deal with situations in which their adolescent becomes
anxious.
Sessions include explanations of CBT techniques, real-life ex-
amples to demonstrate how each skill can be implemented, and an
opportunity for the participant to apply the technique to their own
anxiety-provoking situations. Homework exercises are set follow-
ing each session and are reviewed at the beginning of the next
session. The sessions are designed to be engaging, interactive, and
age-appropriate. Eye-catching graphics, sounds, games, and quiz-
zes are used to maintain the adolescents’ level of interest. Infor-
mation is presented through interactive exercises in which material
is presented followed by quizzes and tasks that check for correct
understanding and provide corrective feedback where required. To
avoid activities being skipped, most exercises require a response to
be given in order for the adolescent or parent to move on to the
next page of the session. The content of the intervention is de-
signed to meet the developmental and cognitive level of teenagers,
with age-appropriate scenarios, examples, and activities (example
situations include school exams, job interviews, dating, and oral
presentations). Throughout the program peer modeling is utilized
to teach therapeutic skills. Adolescent characters introduced in the
first treatment session are used throughout the program to depict
the target anxiety disorders and demonstrate implementation of
therapeutic skills in a variety of settings. The program also uses
age-appropriate terminology to maximize client engagement (e.g.,
cognitive restructuring is referred to as “reality checking”). Fur-
thermore, more advanced cognitive concepts were introduced in
the adolescent program, such as the role of cognitive distortions. A
full discussion of developmental considerations addressed in the
construction of the program is provided by Spence et al. (2008).
The program is delivered through 10 weekly sessions for adoles-
cents and five sessions for parents, each of approximately 60 min
in duration. At 1 month and 3 months following treatment, booster
sessions are provided for parents and adolescents to consolidate
previously acquired skills. Sessions are accessed via a password
protected website and are completed sequentially (and intended to
be at intervals of 7 days).
The structured nature of CBT makes it relatively straightforward
to adapt session and homework content from a clinic modality to
Internet delivery. The greatest challenge in transferring the pro-
gram from clinic to Internet delivery is in the development of the
exposure hierarchy. This session provides interactive information
to assist the young person to design their hierarchy, with illustra-
tions of hierarchies relevant to different types of anxiety using the
hypothetical anxious teenager characters mentioned above and
quizzes that check for correct understanding. Instructions are given
for completion of exposure tasks between sessions (in vivo) with
exposure task implementation and anxiety levels before, during,
and after exposures being recorded within a diary kept by the
young person. The outcomes of exposure are then submitted in the
subsequent session in response to set computer-based questioning.
Adolescents also receive a 15-min telephone call following Ses-
sion 5, to provide advice and assistance in regards to the construc-
tion and implementation of exposure hierarchies.
Prior to treatment, each family is assigned a therapist (BRAVE
Trainer) who monitors their progress through the program and
provides brief e-mail feedback following each session. Client
responses to all session and homework activities are stored in an
administrator section of the program that is accessible to the
therapist. On the basis of this information, the therapist constructs
a brief feedback e-mail to the client after each session. In addition,
personalized, automated computer-generated e-mails are sent on
behalf of the online therapist to congratulate participants for com-
633
ONLINE CBT FOR ADOLESCENT ANXIETY
pletion of sessions and to provide feedback about responses to quiz
tasks. Seven days after completion of each session, personalized,
automated reminder e-mails are sent, advising that the next session
is available for completion. Finally, personalized, automated re-
minder e-mails are sent if the session is not accessed within 2 days
of becoming available.
Clinicians were provided with set criteria and standard tem-
plates to use when responding by e-mail to each session and could
also insert personalized information relating to session tasks. All
therapists were psychologists who had received a minimum of 2
days training with the BRAVE–ONLINE materials. In addition,
therapists were provided with weekly supervision from an expe-
rienced clinical psychologist. During supervision, the therapist’s
online responses were reviewed in order to maintain a high stan-
dard of integrity and to ensure that each therapist was adhering to
all guidelines for participant contact (e.g., length and content of
session responses, adhering to templates).
Clinic-based treatment (CLIN). In the clinic condition,
participants received the equivalent program to the online ther-
apy in terms of content, length, and number of session activi-
ties, but all sessions were conducted face-to-face with a thera-
pist within a clinic setting. BRAVE–CLINIC is a manualized
individual CBT program for adolescent anxiety (Donovan, Hol-
mes, & Spence, 2006) adapted from the child program evalu-
ated by Spence, Holmes, March, and Lipp (2006). Adolescents
and parents received a workbook to use during the sessions and
a copy of the relaxation CD.
Clinic sessions were conducted by registered psychologists at
The University of Queensland, Griffith University, and Macquarie
University Psychology Clinics. All clinicians received 2 days of
training in the manualized clinic program. Training was conducted
by the program coordinators who were also responsible for pro-
viding ongoing weekly supervision for all clinicians. Following
each session, clinicians were required to complete a checklist of
activities completed with the client. Further, a random subset of
15% of clinic sessions were video recorded for each client and
were watched by an independent observer/therapist to confirm
fidelity of implementation. On average, 95.61% of activities that
should have been completed were completed each session.
Wait list control condition (WLC). Wait list participants
were assessed at baseline and then again after a 12-week waiting
period. The WLC did not have any form of planned contact with
the project team during the 12-week period. They were provided
with contact details for the researchers in the event that serious
clinical deterioration in symptoms took place, although none of the
participants made such contact. Following this period, WLC par-
ticipants were offered NET treatment and subsequently ceased to
be part of the study.
Results
Power
Power calculations were based on chi-square tests using diag-
nostic status as the primary outcome measure. The study was
powered on the comparison between the two active treatment
conditions, as this comparison required the most power. It was
calculated that a sample size of 44 participants per active treatment
group would provide a power of .80 to detect a clinically mean-
ingful (medium) effect size of .30, at an alpha of .05.
Statistical Analysis
Primary outcomes for the investigation were clinical diagnoses
(based on the ADIS–C/P), clinician severity ratings (CSR), and
clinician-rated global functioning (CGAS). Secondary outcomes
included parent ratings of anxiety symptoms on the SCAS–P and
internalizing problems on the CBCL, plus youth self-report on the
SCAS–C and the YSR.
Analyses for the continuous variables were conducted using an
intention-to-treat (ITT) approach and included all participants who
were randomly assigned to conditions. Mixed model, repeated-
measures analyses using SPSS Mixed were used separately to
evaluate the continuously scaled outcome measures over time as a
function of treatment condition. Maximum-likelihood estimation
was used to determine parameter estimates. Treatment condition
was regarded as a fixed between-groups effect, with time taken as
a fixed, repeated-measure, within-subject effect, and the intercept
as a random effect. Main effects for treatment condition were
based on estimated scores at each time point. For categorical
diagnostic results, data were examined for ITT and completer
samples, using chi-square tests.
The analyses first examined differences between the three ex-
perimental conditions (WLC, NET, and CLIN) from baseline to
the 12-week assessment point. Then, because the WLC partici-
pants were not included in the follow-up component of the study,
separate analyses were conducted across four assessment occa-
sions (baseline, 12-week assessment, and 6- and 12-month follow-
ups) comparing the NET and CLIN conditions.
Baseline Comparisons
Initial differences between the three experimental conditions
were examined for baseline demographic and treatment outcome
measures. No significant differences were evident for demographic
variables including age, gender, family income, or parental edu-
cation. Significant baseline differences were evident across con-
ditions, however, for the primary outcome measures of CSR, F(2,
112) 5.12, p.007,
2
.084, and CGAS, F(2, 112) 4.41,
p.014,
2
.072. Post hoc contrasts (Scheffe) indicated
significantly higher anxiety severity on the CSR, t(112) –3.07,
p.01, and poorer functioning on the CGAS, t(112) 2.96, p
.02, in the CLIN condition compared with the WLC condition at
baseline but not between CLIN versus NET or NET versus WLC
conditions.
Impact of Missing Data
There were no significant differences in baseline levels of
primary and secondary outcome variables or demographic charac-
teristics of the child and family between participants who were
retained in the study compared with those who were missing at one
or more assessment occasions. Dummy variables were computed
for the primary outcome measures in which the number of occa-
sions in which there was a missing value on that variable was
computed. There were no significant interactions between miss-
634 SPENCE ET AL.
ingness and the condition by time interaction, or with time or
condition for either CSR or CGAS ratings.
Treatment Expectancy and Credibility Ratings
No significant differences in adolescent outcome expectancy
and perception of treatment credibility at the end of the first
treatment session were found between the two treatment groups,
t(81) – 0.91, p.37, two-tailed (NET Mitem score 6.57,
SD 1.49; CLIN Mitem score 6.88, SD 1.60), where scores
ranged from 0 –9. Similarly, there was no significant difference in
treatment expectation and perception of treatment credibility be-
tween parents in NET and CLIN conditions, t(83) –1.11, p
.27, two-tailed (NET Mitem score 7.08, SD 1.05; CLIN M
item score 7.30, SD 0.75). These ratings are similar to those
found for a previous Internet-based intervention using the same
measure (March et al., 2009) and indicate a moderate to strong
expectancy for positive outcome and credibility of both treatment
approaches.
Completion of Therapy Sessions
The average number of sessions completed by NET partici-
pants at the 12-week assessment point was 7.5 out of 10 for
adolescents and 4.48 out of 5 for parents, although only 39% of
adolescents and 66% of parents had completed all of their
treatment sessions at this point. This was not significantly
different to that of CLIN families, who completed on average
8.25 out of 10 sessions for adolescents and 4.43 out of 5
sessions for parents, with 57% of adolescents and 70% of
parents completing all treatment sessions by the 12-week as-
sessment. Families in both conditions completed further ses-
sions over the next few weeks. The rate of session completion
was, however, significantly slower in the NET than the CLIN
group, with a mean rate of session completion of 1 session per
14.00 (SD 7.28) days for the NET participants compared with
1 per 8.96 (SD 3.09) days for the 32 CLIN adolescents from
whom these data were available, F(1, 74) 13.50, p.001,
2
.15.
By 12-month follow-up, adolescents in the NET condition had
completed an average of 8.20 out of 10 sessions and parents had
completed 4.70 out of 5 sessions, with 57% of adolescents and
79% of parents completing all treatment sessions. In the CLIN
condition, by 12-month follow-up, adolescents had completed an
average of 8.70 out of 10 sessions and parents had completed 4.50
out of 5 sessions, with 79% of adolescents and 79% of parents
completing all sessions. No significant differences were evident
between NET and CLIN adolescents or parents in terms of the
mean number of sessions completed by 12-month follow-up. How-
ever, significantly fewer NET adolescents had completed all 10
sessions by 12-month follow-up, compared with the CLIN group,
2
(1, N88) 5.24, p.02.
Outcome: Baseline to 12-Week Assessment Effects
Primary outcome measures: Diagnostic data. Diagnostic
status was determined on the basis of combined parent and ado-
lescent reports on the ADIS–P and –C. Diagnostic status was
considered both in terms of the percentage of children who no
longer met Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM–IV; American Psychiatric Association, 1994) crite-
ria for their primary anxiety disorder and for any anxiety disorder.
For this categorical data, results are reported for both completer
and ITT samples (see Table 1). For the purposes of the ITT
sample, participants without 12-week assessment data were as-
sumed to still possess their pre-treatment diagnoses at 12 weeks.
Table 1
Diagnostic Outcome Measures at Each Assessment Point
Variable NET CLIN WLC
Percentage free of primary anxiety diagnosis
12-week assessment
Completer sample 15/41 (36.6%) 13/40 (32.5%) 1/24 (4.2%)
Intent-to-treat sample 15/44 (34.1%) 13/44 (29.5%) 1/27 (3.7%)
6-month follow-up
Completer sample 23/37 (62.2%) 21/36 (58.3%)
Intent-to-treat sample 24/44 (54.5%) 22/44 (50.0%)
12-month follow-up
Completer sample 29/37 (78.4%) 29/36 (80.6%)
Intent-to-treat sample 30/44 (68.2%) 30/44 (68.2%)
Percentage free of any anxiety diagnosis
12-week assessment
Completer sample 8/41 (19.5%) 9/40 (22.5%) 1/24 (4.2%)
Intent-to-treat sample 8/44 (18.2%) 9/44 (20.5%) 1/27 (3.7%)
6-month follow-up
Completer sample 20/37 (54.1%) 18/36 (50.0%)
Intent-to-treat sample 20/44 (45.5%) 18/44 (40.9%)
12-month follow-up
Completer sample 23/37 (62.2%) 26/36 (72.2%)
Intent-to-treat sample 24/44 (54.5%) 26/44 (59.1%)
Note. Completer sample included participants with data available at the 12-week assessment time point. For the
intent-to-treat sample, missing values were replaced by the value at the previous time point (e.g., diagnosis was
retained from the baseline value). NET Internet-based treatment; CLIN clinic-based treatment; WLC
wait list control.
635
ONLINE CBT FOR ADOLESCENT ANXIETY
For the completer sample, analyses were conducted with partici-
pants for whom diagnostic data were actually available at the
12-week assessment.
Primary anxiety disorder: Clinically significant improvement.
Clinically significant improvement was examined using the per-
centage of adolescents who were free of their primary diagnosis at
12-week assessment. The criterion for diagnosis free required the
CSR for the primary diagnosis to be at a subclinical level (3 or
lower). When considering the ITT sample, a significant difference
was found between conditions (see Table 1),
2
(2, N115)
8.90, p.01. Post hoc comparisons revealed significant differ-
ences between the WLC and NET conditions,
2
(1, N71)
8.85, p.003, and between WLC and CLIN conditions,
2
(1,
N71) 7.06, p.008, but not between NET and CLIN groups,
2
(1, N88) 0.21, p.65.
Similar results were found for the completer sample, with a
significant overall difference between conditions,
2
(2, N
105) 8.73, p.01. Post hoc comparisons for the completer
sample revealed significant differences between the WLC and
NET conditions,
2
(1, N65) 8.57, p.003, and between
WLC and CLIN conditions,
2
(1, N64) 7.05, p.008, but
not between NET and CLIN groups,
2
(1, N81) 0.15,
p.70.
Any anxiety disorder. An evaluation of the percentage of
adolescents in the ITT sample who no longer met criteria for any
anxiety disorder at the 12-week assessment failed to find a signif-
icant difference between the three conditions,
2
(2, N115)
3.90, p.14 (see Table 1). For the completer sample, there was
also no significant difference between conditions,
2
(2, N
105) 3.82, p.15.
Primary outcome measures: Continuous measures. A lin-
ear mixed model analysis was conducted to compare the three
conditions over time from baseline to the 12-week assessment for
primary and secondary continuous outcome measures. Given the
significant baseline differences between conditions, analyses were
initially conducted using the baseline CSR as a covariate. How-
ever, as there was no significant effect of baseline CSR upon
change over time in the primary outcome measures, the analyses
reported here do not include baseline CSR as a covariate in order
to facilitate interpretation of the data. Table 2 summarizes the
estimated marginal means for primary and secondary outcome
measures.
For the primary outcome measures, the analyses conducted on
CSR scores revealed a significant effect for treatment condition,
F(2, 116.35) 3.63, p.03; time, F(1, 113.27) 91.42, p
.001; and a significant treatment by time interaction, F(2,
113.14) 15.58, p.001. Post hoc contrasts revealed significant
changes over time for the NET, F(1, 111.85) 72.87, p.001,
and CLIN conditions, F(1, 113.09) 83.39, p.001, but not for
the WLC. Results pertaining to fixed effects for intercept and
slopes and effect sizes are shown in Table 3 and indicate that both
NET and CLIN conditions decreased in CSR scores significantly
more than the WLC from baseline to 12-week assessment.
For the CGAS ratings, there was no significant effect for treat-
ment condition, F(2, 117.12) 1.11, p.33, but a significant
effect for time, F(1, 111.36) 124.52, p.001, and a significant
treatment by time interaction, F(2, 111.29) 18.49, p.001. Post
hoc comparisons indicated no significant change for the WLC,
but significant increases (improved functioning) in CGAS scores
for NET, F(1, 110.34) 105.51, p.001, and CLIN groups, F(1,
111.25) 99.34, p.001. Both the NET and CLIN conditions
showed significantly greater increases than the WLC in CGAS
scores from baseline to 12-week assessment (see Table 3).
Secondary outcome measures: Continuous measures. For
the secondary outcome measures, significant effects were found
for time on the SCAS–C, F(1, 102.06) 63.43, p.001, with
CLIN, F(1, 100.76) 33.58, p.001; NET, F(1, 102.73)
24.90, p.001; and WLC, F(1, 102.41) 12.04, p.01, all
showing a significant reduction in symptoms over time. The parent
report SCAS–P also showed a significant time effect, F(1,
103.19) 10.97, p.001, although post hoc analyses revealed
that only the CLIN condition reported a significant reduction in
symptoms over time, F(1, 104.62) 3.27, p.001. For the
CBCL and YSR, there were significant effects for time, F(1,
109.80) 38.46, p.001, and treatment condition, F(1,
101.78) 75.90, p.001, respectively. Post hoc contrasts indi-
Table 2
Estimated Marginal Means and Standard Errors for Continuous Variables From Baseline to 12-Week Assessment
Measure Time
WLC NET CLIN
MSEd MSEd MSEd
CSR Baseline 5.67 0.16 5.91 0.13 6.30 0.13
12 weeks 5.50 0.34 0.24 3.85 0.26 2.12 4.08 0.27 3.42
CGAS Baseline 52.74 1.13 49.86 0.89 48.43 0.89
12 weeks 54.04 1.95 0.35 61.83 1.49 1.56 60.18 1.51 2.11
SCAS–C Baseline 36.26 3.34 40.98 2.62 41.89 2.62
12 weeks 26.52 3.18 1.32 27.78 2.41 1.23 31.54 2.51 1.09
SCAS–P Baseline 27.15 2.49 27.43 1.95 33.91 1.95
12 weeks 25.22 2.27 0.23 23.59 1.70 0.33 26.78 1.79 0.84
CBCL Baseline 66.52 1.59 68.59 1.24 68.86 1.24
12 weeks 64.26 1.88 0.32 62.22 1.41 1.01 61.27 1.48 1.25
YSR Baseline 62.00 1.99 64.96 1.53 65.25 1.53
12 weeks 57.57 2.40 0.72 54.20 1.82 1.64 56.84 1.89 1.33
Note. Effect sizes expressed as Cohen’s dfrom baseline to 12-week assessment within conditions. WLC wait list control; NET Internet-based
treatment; CLIN clinic-based treatment; CSR clinician severity rating; CGAS Children’s Global Assessment Scale; SCAS–C/P Spence
Children’s Anxiety Scale—Child and Parent Versions; CBCL Child Behavior Checklist; YSR Youth Self-Report.
636 SPENCE ET AL.
cated that those in the CLIN condition showed a significant re-
duction in scores over time on the CBCL, F(1, 111.07) 29.05,
p.001, and YSR, F(1, 101.70) 36.12, p.001. The NET
condition also showed significant reductions in scores on the
CBCL over time, F(1, 107.13) 23.10, p.001, and the YSR,
F(1, 99.69) 54.18, p.001. In contrast, the WLC showed no
significant reduction over time for the CBCL, but a small yet
significant reduction in scores was evident for the YSR, F(1,
103.02) 6.97, p.05, from baseline to 12-week assessment.
There were no significant condition by time interactions or con-
dition effects from baseline to 12-week assessment on any of the
secondary outcome measures. When adolescent gender was in-
cluded in the model, there were no significant interaction effects
between gender, condition, and time.
Outcome: Baseline to 12-Week Assessment and 6- and
12-Month Follow-Ups
Primary outcome measures: Diagnostic data. Follow-up
data were examined only for the NET and CLIN treatment condi-
tions, as the WLC participants were not available beyond the
12-week assessment point. For the purposes of the ITT sample,
missing data at 6- and 12-month follow-up were replaced with the
value from the previous time point at which they provided assess-
ment data.
Clinically significant change at 6-month follow-up. The
percentage of adolescents in the ITT sample who no longer met
DSM–IV criteria for their primary anxiety disorder continued to
increase from 12-week assessment to 6-month follow-up, for both
NET and CLIN conditions (see Table 1), suggesting that diagnos-
tic status was further improved over time. Similar improvements
were evident for both treatment conditions in the completer sam-
ple. There were no significant differences between treatments for
either the ITT,
2
(1, N88) 0.18, p.67, or completer
samples,
2
(1, N73) 0.11, p.74. Participants also contin-
ued to improve at 6-month follow-up with respect to the presence
of any anxiety disorder (see Table 1). Again, there were no
significant differences between treatment conditions for either the
ITT,
2
(1, N88) 0.19, p.67, or completer samples,
2
(1,
N73) 0.12, p.73.
Clinically significant change at 12-month follow-up. Diag-
nostic improvements continued to be seen from 6- to 12-month
follow-up for both treatment conditions in the ITT and completer
samples (see Table 1), with no significant treatment differences for
either the ITT,
2
(1, N88) 0.00, p1.00, or completer
samples,
2
(1, N73) 0.05, p.82, in terms of primary
anxiety disorder. This pattern of continued improvement was also
found for any anxiety disorder (see Table 1), again with no
significant difference between conditions, for either the completer
or ITT samples,
2
(1, N88) 0.19, p.67, and
2
(1, N
73) 0.84, p.36, respectively.
Primary outcome measures: Continuous measures. A lin-
ear mixed model analysis was then used to examine differences in
primary outcome measures across the four time points for the two
treatment conditions. Outcomes at each assessment occasion are
reported in Table 4. There was a significant effect for time for CSR
ratings, F(3, 238.17) 139.05, p.001, and the CGAS, F(3,
236.01) 173.81, p.001. There were no significant effects for
condition or between condition and time for the primary outcome
Table 3
Effects for NET, CLIN, and WLC Conditions From Baseline to 12 Weeks for Outcome Measures From Baseline to 12-Week Assessment
Variable
CSR CGAS SCAS–C SCAS–P CBCL YSR
BSEES BSEES BSEES BSEES BSEES BSEES
Intercept
WLC baseline 5.67
ⴱⴱ
0.25 4.33 52.74
ⴱⴱⴱ
1.50 0.73 36.26
ⴱⴱⴱ
3.19 0.00 27.15
ⴱⴱⴱ
2.32 2.25 66.52
ⴱⴱⴱ
1.65 7.76 62.25
ⴱⴱⴱ
2.12 5.71
NET–WLC 0.24 0.32 0.19 2.88 1.91 0.03 4.72
ⴱⴱ
4.05 0.01 0.28 2.95 0.02 2.07 2.10 0.24 2.70 2.68 0.25
CLIN–WLC 0.63
0.32 0.48 4.31
1.91 0.08 5.63
ⴱⴱⴱ
4.05 0.00 6.76
2.95 0.56 2.35 2.10 0.27 3.00 2.68 0.28
Slope baseline–12 weeks
WLC slope 0.15 0.31 0.12 1.34 1.50 0.02 9.35
2.69 0.02 1.54 2.69 0.13 2.28 1.75 0.27 4.83
ⴱⴱ
1.83 0.44
NET–WLC slope 1.89
ⴱⴱⴱ
0.39 1.45 10.54
ⴱⴱⴱ
1.90 0.24 2.54 3.39 0.00 2.65 3.37 0.22 4.09 2.20 0.48 5.26
2.29 0.48
CLIN–WLC slope 2.05
ⴱⴱⴱ
0.39 1.57 10.30
ⴱⴱⴱ
1.90 0.26 1.24 3.43 0.00 5.92 3.42 0.49 5.15
2.23 0.60 3.69 2.32 0.34
Random effects
Level 1 residual variance 1.21 27.85 85.46 86.76 36.62 38.13
Level 2 residual variance 0.50 33.22 188.45 58.52 36.83 80.65
Note. Effect sizes calculated as the estimated fixed effects divided by the square root of the sum of the two variance components. NET Internet-based treatment; CLIN clinic-based treatment;
WLC wait list control; CSR clinician severity rating; CGAS Children’s Global Assessment Scale; SCAS–C/P Spence Children’s Anxiety Scale—Child and Parent Versions; CBCL Child
Behavior Checklist; YSR Youth Self-Report.
p.05.
ⴱⴱ
p.01.
ⴱⴱⴱ
p.001.
637
ONLINE CBT FOR ADOLESCENT ANXIETY
measures. Table 5 provides the parameter estimates and effect
sizes for the mixed model analysis. Thus, both CLIN and NET
conditions decreased in anxiety severity and increased in overall
functioning to the same extent over time. When gender of adoles-
cent was included in the models, there were no significant inter-
action effects between gender, condition, and time.
Secondary outcome measures: Continuous measures.
There was a significant main effect of time on the SCAS–C, F(3,
217.27) 96.11, p.001; the SCAS–P, F(3, 217.08) 61.27,
p.001; the CBCL—Internalizing, F(3, 216.69) 55.91, p
.001; and the YSR—Internalizing scores, F(3, 219.12) 66.31,
p.001. However, there were no significant condition or condi-
tion by time interaction effects, indicating that adolescents in both
conditions showed significant and equivalent decreases in anxiety
symptoms over time. Table 5 shows the parameter estimates and
effect sizes for the mixed model analysis and demonstrates that
there were no significant differences in changes over time between
the CLIN and NET conditions for the secondary outcome mea-
sures.
Satisfaction With the Program
Satisfaction data were collected for 40 adolescents and 41
parents in the NET condition and for 36 adolescents and 37 parents
in the CLIN condition. For adolescent reports of treatment satis-
faction, there were no significant differences between the NET
(M3.53, SD 0.73) and CLIN (M3.79, SD 0.95)
conditions, t(76) –1.36, p.18, two-tailed. However, parents in
the CLIN condition (M3.99, SD 0.69) reported significantly
higher satisfaction with the program than parents in the NET
condition (M3.57, SD 0.81), t(78) –2.42, p.02,
two-tailed. Overall, the results indicate that adolescents and par-
ents reported moderate to high satisfaction with the treatment
received, although parents in the CLIN condition reported slightly
higher program satisfaction.
Discussion
The results of the study demonstrate the significant benefits of
online delivery of CBT for the treatment of anxiety disorders
amongst adolescents, with outcomes at 12-month follow-up being
similar to those found for clinic-based therapy. Furthermore, the
online program was regarded as a highly credible approach by both
parents and adolescents, at a level equivalent to clinic-based CBT,
and produced moderate to high ratings of satisfaction with treat-
ment. Both Internet and clinic-based CBT produced significantly
greater reductions in clinician-rated anxiety and greater improve-
ments in overall functioning than the wait list group at the 12-week
assessment point, with no significant difference between treatment
formats. The short-term effects were equivocal for the self-report
questionnaires completed by the parents and adolescents.
Table 4
Estimated Marginal Means and Standard Errors for Continuous Variables From Baseline to 12-
Week Assessment and 6- and 12-Month Follow-Ups for NET and CLIN Conditions
Measure Time
NET CLIN
MSEd MSEd
CSR Baseline 5.91 0.12 6.30 0.12
12 weeks 3.85 0.29 4.08 0.29
6-month fup 2.60 0.32 2.89 0.33
12-month fup 1.97 0.34 2.58 1.81 0.35 3.88
CGAS Baseline 49.86 0.89 48.43 0.89
12 weeks 61.83 1.63 60.18 1.65
6-month fup 70.46 1.84 68.19 1.87
12-month fup 72.05 1.85 2.90 72.53 1.88 3.91
SCAS–C Baseline 40.98 2.62 41.89 2.62
12 weeks 27.78 2.48 31.54 2.58
6-month fup 22.52 2.59 22.62 2.45
12-month fup 20.20 2.42 1.85 17.94 2.49 2.08
SCAS–P Baseline 27.43 1.98 33.91 1.98
12 weeks 23.59 1.69 26.78 1.77
6-month fup 16.82 1.57 17.53 1.51
12-month fup 15.86 1.47 1.08 15.26 1.49 2.15
CBCL Baseline 68.59 1.33 68.86 1.33
12 weeks 62.22 1.53 61.27 1.61
6-month fup 58.88 1.80 56.28 1.74
12-month fup 55.39 2.01 1.76 55.89 2.11 1.80
YSR Baseline 64.96 1.54 65.25 1.54
12 weeks 54.20 1.88 56.84 1.96
6-month fup 51.94 2.01 52.32 1.90
12-month fup 49.29 2.24 1.67 49.91 2.31 1.65
Note. Effect sizes expressed as Cohen’s dfrom baseline to 12-month assessment within conditions. NET
Internet-based treatment; CLIN clinic-based treatment; CSR clinician severity rating; CGAS Children’s
Global Assessment Scale; SCAS–C/P Spence Children’s Anxiety Scale—Child and Parent Versions;
CBCL Child Behavior Checklist; YSR Youth Self-Report; fup follow-up.
638 SPENCE ET AL.
Table 5
Effects for NET and CLIN Conditions Across Time From Baseline to 12-Month Follow-Up for Continuous Outcome Measures
Variable
CSR CGAS SCAS–C SCAS–P CBCL YSR
BSEES BSEES BSEES BSEES BSEES BSEES
Intercept
CLIN baseline 6.30
ⴱⴱⴱ
0.26 3.67 48.43
ⴱⴱⴱ
1.47 4.98 41.89
ⴱⴱⴱ
2.40 2.63 33.91
ⴱⴱⴱ
1.66 3.09 68.86
ⴱⴱⴱ
1.48 7.00 65.25
ⴱⴱⴱ
1.77 5.54
CLIN–NET 0.39 0.37 0.23 1.43 2.07 0.15 0.91 3.40 0.06 6.48
2.34 0.59 0.27 2.10 0.03 0.30 2.51 0.03
Slope
Slope CLIN baseline to
12 months 4.47
ⴱⴱⴱ
0.31 2.61 23.90
ⴱⴱⴱ
1.57 2.46 24.64
ⴱⴱⴱ
2.14 1.55 18.37
ⴱⴱⴱ
1.79 1.67 12.68
ⴱⴱⴱ
1.56 1.29 15.45
ⴱⴱⴱ
1.75 1.31
Slope CLIN baseline to
6 months 3.38
ⴱⴱⴱ
0.31 1.97 19.57
ⴱⴱⴱ
1.57 2.01 19.51
ⴱⴱⴱ
2.06 1.22 16.33
ⴱⴱⴱ
1.77 1.49 12.13
ⴱⴱⴱ
1.43 1.23 13.02
ⴱⴱⴱ
1.68 1.11
Slope CLIN baseline to
12 weeks 2.20
ⴱⴱⴱ
0.30 1.28 11.65
ⴱⴱⴱ
1.51 1.20 10.59
ⴱⴱⴱ
2.06 0.66 7.54
ⴱⴱⴱ
1.75 0.69 7.40
ⴱⴱⴱ
1.42 0.75 8.51
ⴱⴱⴱ
1.68 0.72
Slope to 12 months
CLIN vs. NET 0.57 0.44 0.33 2.05 2.20 0.21 3.05 2.99 0.19 6.81 2.50 0.62 0.52 2.17 0.05 0.41 2.44 0.04
Slope to 6 months CLIN
vs. NET 0.09 0.44 0.05 0.56 2.20 0.06 0.05 2.96 0.00 5.98 2.53 0.54 2.77 2.04 0.28 0.63 2.42 0.05
Slope to 12 weeks CLIN
vs. NET 0.16 0.42 0.09 0.24 2.13 0.02 1.55 2.86 0.10 3.39 2.43 0.31 1.03 1.97 0.10 1.72 2.34 0.15
Random effects
Level 1 residual variance 1.87 46.75 80.60 59.08 38.53 54.10
Level 2 residual variance 1.08 47.74 173.10 61.72 58.37 84.41
Note. Effect sizes calculated as the estimated fixed effects divided by the square root of the sum of the two variance components. NET Internet-based treatment; CLIN clinic-based treatment;
CSR clinician severity rating; CGAS Children’s Global Assessment Scale; SCAS–C/P Spence Children’s Anxiety Scale—Child and Parent Versions; CBCL Child Behavior Checklist; YSR
Youth Self-Report.
p.05.
ⴱⴱⴱ
p.001.
639
ONLINE CBT FOR ADOLESCENT ANXIETY
Overall, the outcomes for both the CLIN and NET groups at
12-week post-baseline tended to be somewhat lower than those
reported for clinic-based therapy (Cartwright-Hatton et al., 2004;
James et al., 2008; Silverman et al., 2008). The rates are also lower
than the post-treatment remission rates reported by the same re-
search team using the same intervention with a younger sample
using a combined clinic-Internet condition (Spence, Holmes,
March, & Lipp, 2006). They are, however, consistent with those
reported in a recent study by Hudson et al. (2009) in which 45%
of the 7–16-year-old sample were free of their primary anxiety
diagnosis immediately after CBT. Similarly, the extent of the
clinically significant improvements in the CGAS ratings for the
NET and CLIN conditions at 12 weeks are consistent with those
reported by Walkup et al. (2008) over the same time period for
clinic-based CBT with 7–17-year-olds.
It may be that anxiety disorders are of longer duration in the
older age group and possibly more difficult to treat. Alternatively,
the weak results at 12 weeks may reflect the finding that a
significant number of families in both the clinic and Internet
conditions had yet to complete all 10 sessions by this point. This
finding is consistent with that reported by March et al. (2009)
using online therapy with children but is somewhat unexpected for
the CLIN condition. Post-assessments were conducted at 12 weeks
post-baseline assessment regardless of whether participants had
completed all sessions to allow comparisons with results at the
same time point across the three conditions, and with other clinic-
based efficacy trials in this area. It is difficult to determine whether
the rates of adolescent therapy session completion in the present
study are different from those in the clinic-based literature, given
that such information is rarely reported. It may be that adolescents
are more reluctant, busier, or less motivated than younger children
and that this contributes to the lower than expected rates of session
completion and, in turn, to lower rates of improvement. The
teenagers in both treatments did, however, continue to complete
sessions over the next few weeks, although those in the NET
condition were less likely to have completed all 10 sessions by
12-month follow-up.
The results indicate that over the 12-month follow-up period, the
majority of young people continued to improve in both treatment
conditions, with no significant differences in treatment outcome
across therapy formats. It appears therefore that even though the
Internet participants were less likely to have completed all 10
sessions, their clinical outcome was equivalent to that found for the
clinic-based group in the longer term. By 12-month follow-up,
78.4% and 80.6% of young people in the NET and CLIN condi-
tions, respectively, in the completer sample were free of their
primary diagnosis, indicating a level of improvement that is con-
sistent with the results for CBT at a similar follow-up point
elsewhere in the literature (Cartwright-Hatton et al., 2004; James
et al., 2008; Silverman et al., 2008). Although the rates relating to
the ITT sample were lower, again these were consistent with
results reported in other studies for clinic-based therapy. In addi-
tion to improvements in diagnostic status, both conditions showed
continued and significant improvements in anxiety symptoms ac-
cording to both parent and youth reports, and significant enhance-
ments in overall functioning on the clinician-rated CGAS.
It should be noted, however, that even though both conditions
showed equivalent and strong effects upon the primary diagnoses,
the effects were weaker in terms of change in “any anxiety diag-
nosis,” with 62.2% of NET and 72.2% of CLIN completers no
longer experiencing any anxiety diagnoses. The difference be-
tween conditions was not statistically significant, but it is of
concern that a significant proportion of participants in both con-
ditions still experienced at least one clinically significant anxiety
problem at 12-month follow-up (37.8% in the NET and 27.8% in
the CLIN conditions). This point tends to be masked if reliance is
placed on the CSR of the primary diagnosis as the main outcome
measure. For this reason, future studies should consider using an
indicator of improvement that takes into account functioning
across anxiety problems in general, such as the Clinician Global
Impressions—Improvement rating (CGI–I; Guy & Bonato, 1970).
It is feasible that both clinic and Internet CBT of the length and
type of content used in this study may not be sufficient to bring
about significant improvements across the broad spectrum of anx-
iety symptoms in those young people with more complex, comor-
bid presentations. Indeed, Walkup et al. (2008) found that a com-
bination of CBT and medication (sertraline) was more effective
than either approach alone using the CGI–I as the main outcome
measure, suggesting that CBT alone may not be sufficient for some
clients.
One of the encouraging findings in the present study was that
the Internet program was evaluated positively by the participants.
Adolescent consumer ratings indicated a high degree of satisfac-
tion with the therapy, and there were no significant differences
between clinic and Internet delivery groups in the degree of
program satisfaction. However, although the difference was small
and all parents rated the online program positively, parents in the
NET condition rated the treatments significantly lower than did
parents in the CLIN format. It appears that parents do still prefer
face-to-face contact with a therapist when their adolescent is being
treated for anxiety.
The study had several strengths that should be noted. It appears
to be the first randomized controlled trial comparing Internet
versus clinic delivery of CBT for anxiety disorders that focuses
specifically upon an adolescent sample and that includes a wait list
control. The methodology included blind assessment of diagnostic
status, strong fidelity checks for quality of implementation, and a
sample size that provided sufficient power to enable a valid com-
parison between treatments.
There are, however, some limitations in the design of the study.
The first relates to the timing of assessments and equivalence of
therapy completion across conditions. Although the use of com-
mon assessment time points across conditions can be regarded as
a strength of the study, it must be noted that a significant propor-
tion of adolescents in both the NET and CLIN conditions had not
completed all 10 therapy sessions by the 12-week assessment.
Although participants in both conditions continued to complete
sessions over the following weeks, NET participants tended to
work more slowly through their sessions and were less likely to
have completed all 10 sessions by the final assessment time point.
The potential implications of these confounds must be considered.
On the one hand, it is possible that the results for the NET
condition may have been stronger had more of the NET partici-
pants completed all 10 sessions. On the other, it is feasible that the
clinic-based CBT results may have been stronger if the spacing
between sessions had been longer in the CLIN condition, facili-
tating consolidation of coping skills. These issues present some
interesting themes for future research, such as identifying ways of
640 SPENCE ET AL.
increasing the proportion of online participants who completed all
sessions and examining whether clinic-based CBT may be more
effective if the time between therapy sessions is extended. It will
also be important to determine the extent to which outcome from
Internet-delivered CBT is influenced by therapy adherence (such
as the number of exposures completed, number of therapy tasks
completed, or time spent completing the sessions).
A further limitation of the study was the failure to include an
attention placebo control group to enable conclusions to be drawn
about the specific effects of treatment, over and above nonspecific
factors. A recent study by Hudson et al. (2009) suggested, how-
ever, that effects following a nonspecific intervention are signifi-
cantly less than those associated with CBT with clinically anxious
children and adolescents. Thus, the positive results for treatment at
follow-up are unlikely to reflect nonspecific factors. The design of
the present study was also weakened by the absence of the wait list
condition at follow-up. It was not considered ethical to continue
the wait list condition beyond the 12-week assessment point, and
participants in this condition then received the Internet treatment
and ceased to be part of the study. Although it cannot be said for
certain that the positive outcomes at follow-up were not just
reflective of spontaneous remission/natural recovery, this possibil-
ity is unlikely given that the Hudson et al. (2009) study found only
45.5% of young people in a nonspecific control condition to be
diagnosis free at 6-month follow-up. This value is considerably
lower than that for both treatments in the present study.
Another weakness of the current study concerned the character-
istics of the sample, which tended to include quite well-educated
parents with relatively good incomes. Future research should ex-
amine the efficacy of such interventions with families from a
broader range of sociodemographic backgrounds and those who
are referred to community-based clinics (rather than a university
research clinic), in order to determine the generalizability of the
findings.
The study was also restricted to four types of primary presenting
anxiety disorder, namely, generalized anxiety disorder, social pho-
bia, separation anxiety disorder, or specific phobia. Those with a
primary anxiety disorder involving panic disorder, obsessive-
compulsive disorder, or post-traumatic stress disorder were ex-
cluded. Future studies should investigate the feasibility and effec-
tiveness of the online CBT intervention with these additional
anxiety diagnoses.
In summary, the results of the present study suggest that online
CBT, with minimal therapist contact, for adolescent anxiety dis-
orders offers an efficacious alternative to clinic-based treatment.
Online CBT may represent one way in which a greater number of
clinically anxious young people can be helped effectively than can
be achieved solely through clinic-based interventions. Parents and
adolescents regarded the online approach to be credible, with
moderate to high levels of satisfaction. Online therapy reduces the
burden of travel for families, overcomes issues of stigma associ-
ated with attending a clinic, and also requires significantly fewer
therapist hours. In the present study, online support by the therapist
took between 10 –15 min per week (for 10 therapy weeks and 2
booster sessions; total of 120 –180 min), compared with 60 min per
week for 10 youth and 5 parent sessions, plus 2 youth boosters and
2 parent boosters (total of 1,140 min) for clinic treatment. Poten-
tially, a clinician could provide treatment to a larger number of
families using the clinician-assisted online approach than would be
possible using clinic-based therapy alone. It would be valuable in
future research to conduct a more in-depth cost– benefit analysis of
this approach.
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642 SPENCE ET AL.
... They included 4012 participants, with all participants aged in the range of 11 to 19 years and with varying gender balances ( Table 1). The studies targeted various populations (Table S3 in Multimedia Appendix 3 [39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]) and were conducted in a wide range of countries, including New Zealand, China, Japan, Australia, the United Kingdom, the Netherlands, Denmark, and Sweden. Studies had a range of participant exclusion criteria, most often excluding participants who had severe symptoms, had other disorders, were at high risk of self-harm or suicide or were already receiving treatment (Table S3 in Multimedia Appendix 3 [39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]). ...
... The studies targeted various populations (Table S3 in Multimedia Appendix 3 [39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]) and were conducted in a wide range of countries, including New Zealand, China, Japan, Australia, the United Kingdom, the Netherlands, Denmark, and Sweden. Studies had a range of participant exclusion criteria, most often excluding participants who had severe symptoms, had other disorders, were at high risk of self-harm or suicide or were already receiving treatment (Table S3 in Multimedia Appendix 3 [39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]). ...
... The extent of clinician or therapist input varied among interventions but was typically minimal. In addition, most interventions did not require parents to take an active role, with the exception of 19% (3/16) of the studies in which parents received additional guidance to support their adolescents through the course of treatment [39][40][41]. Some of the studies investigated interventions that have been made publicly available, whereas others have not been implemented beyond the research setting. ...
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Background Depression and anxiety are major public health concerns among adolescents. Computerized cognitive behavioral therapy (cCBT) has emerged as a potential intervention, but its efficacy in adolescents remains unestablished. Objective This review aimed to systematically review and meta-analyze findings on the efficacy of cCBT for the treatment of adolescent depression and anxiety. Methods Embase, PsycINFO, and Ovid MEDLINE were systematically searched for randomized controlled trials in English, which investigated the efficacy of cCBT for reducing self-reported depression or anxiety in adolescents aged 11 to 19 years. Titles, abstracts, and full texts were screened for eligibility by 2 independent researchers (TB and LC). A random-effects meta-analysis was conducted to pool the effects of cCBT on depression and anxiety symptom scores compared with the control groups. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool. Results A total of 16 randomized controlled trials were eligible for inclusion in this review, of which 13 (81%) were included in the meta-analysis. The quality of the studies was mixed, with 5 (31%) studies rated as good overall, 2 (13%) rated as fair, and 9 (56%) rated as poor. Small but statistically significant effects of cCBT were detected, with cCBT conditions showing lower symptom scores at follow-up compared with control conditions for both anxiety (standardized mean difference −0.21, 95% CI −0.33 to −0.09; I2=36.2%) and depression (standardized mean difference −0.23, 95% CI −0.39 to −0.07; I2=59.5%). Secondary analyses suggested that cCBT may be comparable with alternative, active interventions (such as face-to-face therapy or treatment as usual). Conclusions This meta-analysis reinforces the efficacy of cCBT for the treatment of anxiety and depression and is the first to examine this exclusively in adolescents. Future research could aim to identify the active components of these interventions toward optimizing their development and increasing the feasibility and acceptability of cCBT in this age group. Trial Registration PROSPERO CRD42019141941; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141941
... A MEDLINE search (year 2000-2021) was performed and found 240 articles using keywords such as "anxiety disorders", "internet", "online", "cognitive-behavioral therapy", "drug treatment", "acceptance", "adherence", "remission", and "progression". Ten articles [15][16][17][18][19][20][21][22][23][24] were selected by selection criteria: (1) Reports written in English, (2) adults with symptoms of anxiety, (3) event rates of treatment effectiveness (remission and relapse) were reported, and (4) CBT acceptance or adherence rates were reported. Preferred studies were meta-analyses or randomized controlled trials. ...
... The model adopted the reported preference for in-person interventions (63.3%) as the acceptance rate for f-CBT, and approximated the relative difference in acceptance of i-CBT versus f-CBT (75.4% versus 63.3%) to be 1.19-fold higher. The adherence rate of 77.5% to f-CBT was estimated from the results reported in two randomized controlled trials on (total 242) participants with symptoms of anxiety [16,17]. A meta-analysis of 24 studies on i-CBT for adolescents and young adults found a mean adherence rate of 76.9% [18]. ...
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This study developed and tested the effectiveness of an app-based cognitive behavioral therapy (CBT) program in alleviating anxiety among adolescents and adults with autism without co-occurring intellectual disability. Thirty participants from 15 to 35 years old were randomly assigned to either the intervention or waitlist control group, and self- and caregiver proxy report questionnaires were administered, accompanied by direct behavior observation before and after the intervention period. There was a significant decrease in anxiety level, an increase in positive affect, and a decline in stereotypic behaviors, hyperactivity, noncompliance, and inappropriate speech in proxy reports for the intervention group, compared to the control group. A significant rise in passive response in the direct observation was also seen in the intervention group.
... Youth mental health services were overburdened early on (Young, 2020), and despite a move to the use of telehealth, more could be done to increase efficiencies in the delivery of mental health services, such as the increased use of evidence-based digital interventions (Spence et al., 2011). Second, the need for additional parent mental health support is highlighted, particularly for parents of younger children who struggled with the challenges of balancing children's home learning and work during lockdowns. ...
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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.
... In contrast to treatment for adults, the treatment of panic disorder in adolescents has been largely neglected, and a considerable number of randomised controlled trials treating anxiety in children and adolescents have excluded young people who have panic disorder as the primary problem [12][13][14]. The most substantial evidence base for CBT for a broad range of anxiety disorders in children and adolescents comes from trials using a general, transdiagnostic treatment approach (e.g. the 'Coping Cat' treatment protocol [15] or the adolescent version, the 'C.A.T. Project' [16]). ...
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Background Panic disorder occurs in between 1 and 3% of adolescents, is associated with high levels of co-morbidity, and without treatment, appears to have a chronic course. To improve access to effective psychological interventions, briefer versions of cognitive behaviour therapy (CBT) have been developed and evaluated for preadolescent children with anxiety disorders. However, there are currently no brief evidence-based CBT interventions for adolescents with anxiety disorders that can be delivered in less than eight sessions. Given that a brief version of cognitive therapy has been shown to be effective in adults with panic disorder, it is possible that an adapted version could be effective for adolescents with panic disorder. Methods The study will examine whether a definitive trial can be conducted, based on a single-centre feasibility randomised controlled trial using several well-defined criteria. Between 30 and 48 young people (age 11–18 years) who meet diagnostic criteria for panic disorder, attending a routine clinical service will be randomly allocated to receive either (i) brief cognitive therapy or (ii) a general form of CBT treatment that is more commonly used for adolescents with anxiety disorders. Both will be delivered 1:1 by a therapist and involve five treatment sessions and two booster sessions. Young people’s outcomes will be assessed at the end of treatment and at 3-month follow-up, and qualitative interviews will be conducted to examine acceptability. We will also explore outcomes 1 year after the completion of treatment. Discussion This study will test the feasibility of a randomised controlled trial to compare brief cognitive therapy to a general form of CBT for adolescents with panic disorder in the UK. The outputs from the study will provide a clear indication of the feasibility of a future definitive trial and, if indicated, the critical resources that will be required and key information to inform the design and maximise the successful completion of the trial. This has the potential to bring direct benefits to young people and their families, as well as services and society more broadly. Trial registration This trial is registered on the ISRCTN Registry, registration number ISRCTN14884288 , registered retrospectively on 05/12/2019.
... Studies on iCBT approaches are encouraging, especially regarding anxiety disorders or depression. The findings of studies, reviews, and meta-analyses in patients (mostly adults, but also in children) suggest that CBT programs with computerized elements (e.g., online material, email contacts) are just as effective as CBT from traditional face-to-face therapies [13][14][15][16][17][18][19][20]. There are also a few studies reporting promising results on patients with OCD [21]. ...
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Background: There has been little research examining attitudes towards computerised therapy in young people. Method: A self-report survey of 37 young people and 31 parents using Child and Adolescent Mental Health Services (CAMHS). Results: Young people reported high levels of computer usage and online help-seeking behaviour. Young people were cautious about computerised therapy whereas parents were more positive, identifying more benefits than concerns. Conclusions: Mental health professionals need to be aware of young people’s online help-seeking behaviour in order to correct inaccuracies and maximise uptake of computerised therapy.
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(from the introduction) In addition to covering issues relevant to the nature and assessment of of anxiety in children and adolescents, this book describes techniques and strategies for the treatment of children's anxiety disorders. The techniques are described in complete detail to allow even relatively inexperienced clinicians to conduct a successful treatment program. Each chapter contains suggested forms and exercises to help implement the strategies. (PsycINFO Database Record (c) 2010 APA, all rights reserved).
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