JMIR Publications

ABSTRACT

Background:

Internet-delivered cognitive behaviour therapy (ICBT) delivered with therapist-guidance has demonstrated efficacy for the treatment of child and adolescent anxiety, though widespread delivery is limited by therapist availability. Self-guided ICBT achieves greater reach, though demonstrates poorer engagement and less clinical benefits. Alternative models of care are required that promote engagement, are effective, accessible, and scalable.

Objective:

This preregistered randomised trial evaluated whether a stepped-care approach to ICBT using therapist guidance via videoconferencing for the step-up component (ICBT-SC(VC)) is non-inferior to therapist-guided ICBT (ICBT-TG(VC)) for child and adolescent anxiety.

Methods:

Participants included 137 Australian children and adolescents aged 7-17 years (61 male), with a primary anxiety disorder. This randomised, non-inferiority trial compared ICBT-SC(VC) to an ICBT-TG(VC) program with assessments conducted at baseline, 12-weeks, and 9-months after treatment commencement. All ICBT-TG(VC) participants received therapist guidance (videoconferencing) after each session, for all 10 sessions. All ICBT-SC(VC) participants completed the first 5 sessions online without therapist guidance. If they demonstrated response to treatment after the first 5 sessions (defined as reductions in anxiety symptoms into the non-clinical range), they continued the online sessions in a self-guided manner (no therapist guidance). If they did not respond, participants were stepped-up to receive supplemental therapist-guidance (videoconferencing) for the remaining sessions. Measures included clinical diagnostic interview with clinician-rated severity rating as the primary outcome, as well as parent and child reported anxiety and anxiety-related interference (secondary outcomes).

Results:

Though there were no significant differences between treatment conditions on primary and almost all secondary outcome measures, tests of non-inferiority did not confirm non-inferiority of ICBT-SC(VC) compared to ICBT-TG(VC). Significant clinical benefits were evident for participants in both treatments, though this was significantly higher for ICBT-TG(VC) participants. Of participants who remained in the study, 68% (41% ITT) of ICBT-SC(VC) and 88% (69% ITT) of ICBT-TG(VC) were free of their primary anxiety diagnosis by 9-month follow-up. Therapy compliance was lower for ICBT-SC(VC) than ICBT-TG(VC), though treatment satisfaction was moderate to high in both conditions.

Conclusions:

This study provided further support for the benefits of low-intensity stepped-care adaptive approaches to ICBT for anxious children and adolescents and highlighted the excellent treatment outcomes that can be achieved through therapist-guided ICBT delivered via videoconferencing. Both treatments may offer an acceptable treatment model that could increase access to evidence-based care. Clinical Trial: The study’s design, hypotheses and analysis plan were preregistered with the Australian and New Zealand Clinical Trials Registry (ACTRN12618001418268).