Internet-delivered cognitive behaviour therapy for paediatric anxiety disorders in clinical settings : increasing access to evidence-based treatments

Background: Paediatric anxiety disorders are common, impairing and associated with a societal and economic burden. Even though there are efficacious treatments to treat these disorders, access to them are limited. Internet-delivered cognitive behaviour therapy (ICBT) has gained support for being an efficacious treatment for paediatric anxiety disorders and is suggested as one possible solution to increase access to evidence-based treatments.

Aims and methods: The main aim of this thesis was to evaluate the BiP Anxiety programme, for children aged 8 to 12 years old with an anxiety disorder, in two clinical settings. First by con­ducting a randomised controlled trial within a specialised ICBT clinic part of the child and adolescent mental health services (CAMHS) in Stockholm. Secondly by conduct­ing a pilot feasibility trial at a CAMHS outpatient clinic in rural Sweden. Specific aims were to evaluate (1) the effects and cost-effectiveness ofICBT compared to an active placebo control, (2) the long term effect of ICBT within a stepped-care model where non-remitters of treatment were offered additional treatment, (3) predictors of treatment outcome, and ( 4) the feasibility and potential effectiveness ofICBT when disseminated in an outpatient clinic in rural Sweden.

Results: ICBT was effective in reducing anxiety symptoms in a cost-effective manner when compared to a placebo condition controlling for non-specific therapeutic factors such as attention and weekly homework assignments. Treatment gains were maintained up to 12 months after the end of the treatment. Participants with a principal diagnosis of separation anxiety disorder, and those more engaged in behaviour change were more likely to be in remission at the three-months follow-up. Participants with more severe anxiety were less likely of being in remission. Additional face-to-face treatment for non-remitters ofICBT was efficacious for those receiving it. The majority of non-remitters however declined this offer down, mostly due to already receiving treatment for other mental health disorders ( e.g., depression) at their local CAMHS. Also, ICBT seemed to be feasible and potentially also effective when disseminated to an outpatient clinic in rural Sweden.

Conclusion: ICBT is an effective treatment, at least for children with moderate anxiety disorders. ICBT could be suitable as a first-line treatment, but a greater understanding about to whom it should be offered and when the treatment should be stepped up is needed. ICBT should be implemented as part of a specialised clinic to ensure the necessary education, support and supervision. However, other models of implementation might be required in rural areas where the resources needed for a specialised clinic cannot be motivated.

List of scientific papers

I. Jolstedt, M., Wahlund, T., Lenhard, F., Ljótsson, B., Mataix-Cols, D., Nord, M., ... & Vigerland, S. (2018). Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial. The Lancet Child & Adolescent Health. 2(11), 792-801.
https://doi.org/10.1016/S2352-4642(18)30275-X

II. Jolstedt, M., Hogstrom, J., Ljótsson, B., Mataix-Cols, D., Wahlund, T., Nord, M., ... & Vigerland, S. Predicting outcome of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders. [Manuscript]

III. Jolstedt, M., Vigerland, S., Mataix-Cols, D., Ljótsson, B., Wahlund, T., Nord, M., ... & Serlachius, E. Long-term outcomes of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders: Towards a stepped care model of health care delivery. [Manuscript]

IV. Jolstedt, M., Ljótsson, B., Fredlander, S., Tedgard, T., Hallberg, A., Ekeljung, A., ... & Vigerland, S. (2018). Implementation of internet­delivered CBT for children with anxiety disorders in a rural area: A feasibility trial. Internet interventions. 12, 121-129.
https://doi.org/10.1016/j.invent.2017.11.003