Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents: A Randomized Clinical Trial
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Importance: In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment. Objective: To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder. Design, Setting and Participants: A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020. Interventions: Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment. Main Outcomes and Measures: The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS. Results: Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group). Conclusions and Relevance: Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT03263546.
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This study presents the first stepped-care CBT protocol for childhood anxiety developed for use in a primary care setting.
“However, to our knowledge, this study presents the first stepped-care CBT protocol for childhood anxiety developed for use in a primary care setting.”
From Developing a primary care-based cognitive behavioral intervention for anxiety in children through a participatory approach: a qualitative study. (2026) · cites this paper as [40]
The Abstract describes a stepped-care CBT trial for children and adolescents with obsessive-compulsive disorder, conducted at two specialist mental health clinics in Sweden—not a childhood-anxiety protocol developed for primary care. The paper also does not establish the claimed ‘first’ status. (LLM, conf=0.88)
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- Authors
- Aspvall, K., Andersson, E., Melin, K., Norlin, L., Eriksson, V., Vigerland, S., Jolstedt, M., Silverberg-Mörse, M., Wallin, L., Sampaio, F., Feldman, I., Bottai, M., Lenhard, F., Mataix-Cols, D., & Serlachius, E.
- Affiliations
- Region Stockholm (SE)
- Karolinska Institutet (SE)
- Sahlgrenska University Hospital (SE)
- Uppsala University (SE)
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Corresponding author
- Aspvall, Kristina
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2021-05-11
- Volume
- 325
- Issue
- 18
- Pages
- 1863
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC8114140
- OpenAlex
- W3160888805
- Cited by
- 66
- References
- 39
- Citations by year
- 2026: 9 · 2025: 14 · 2024: 16 · 2023: 10 · 2022: 11 · 2021: 6
- FWCI
- 7.33
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Karolinska Institutet
- Forskningsrådet om Hälsa, Arbetsliv och Välfärd
- Jane och Dan Olssons Stiftelse
- Region Uppsala
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- obsessive-compulsive disorder, pediatric obsessive-compulsive disorder, internet-based cognitive behavioral therapy, stepped care, non-inferiority, treatment non-responders, Children's Yale-Brown Obsessive Compulsive Scale, children and adolescents, access to mental health care, digital mental health interventions, relapse prevention
- MeSH terms
- Internet-Based Intervention, Adolescent, Anxiety, Child, Depression, Female, Humans, Male, Obsessive-Compulsive Disorder, Sweden, Cognitive Behavioral Therapy, Single-Blind Method
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