Implementation of internet-delivered CBT for children with anxiety disorders in a rural area: A feasibility trial
Open accessAbstract
Child anxiety disorders are highly prevalent and cause significant impairment. Cognitive behavioral therapy (CBT) is recommended for child anxiety disorders, but access to CBT is limited, particularly in rural areas. Internet-delivered CBT (ICBT) can help increase the availability of evidence-based interventions and evidence is beginning to accumulate to indicate that ICBT is efficacious for children with anxiety disorders. However, whether the results of controlled trials are transferrable to real-world clinical settings is unclear. The objective of this study was to evaluate whether therapist-guided ICBT is feasible and potentially effective when implemented in an outpatient clinic in rural Sweden. Children (N = 19) aged 8–12 with anxiety disorders underwent a 12-week ICBT program called BiP Anxiety. Feasibility measures included treatment satisfaction, compliance and feedback from clinicians. Clinical outcome measures were clinician-, parent- and child ratings of anxiety symptoms and functional impairment. Overall, participants and clinicians were satisfied with the treatment content and format. There were statistically significant changes from pre- to post-treatment on the primary outcome measure (t = − 4.371, p < 0.001), as well as on all secondary outcome measures. Therapeutic gains were maintained for up to three months from the post-treatment assessment. At follow-up, 68% were no longer in need of treatment and could be discharged from the clinic. The study suggests the feasibility of implementing ICBT in regular health care. Implementation of ICBT could dramatically increase access to evidence based treatment for children with anxiety disorders who live far away from specialist clinics.
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The effect sizes for BRAVE Self-Help presented in this study are somewhat smaller than those of a pilot implementation study (N=20) conducted by Jolstedt et al.
“The effect sizes for BRAVE Self-Help presented in this study are somewhat smaller than those of a pilot implementation study (N=20) conducted very recently by Jolstedt et al [15].”
From Large-scale dissemination of internet-based cognitive behavioral therapy for youth anxiety: Feasibility and acceptability study (2018) · cites this paper as [15]
The Results (Clinical outcomes measures) report large pre-to-post effect sizes, supporting the description of Jolstedt et al. as a study with which effect sizes could be compared. But the Methods (Participants) and Results (Participants) state that the study included 19 children, not 20; the Data-analysis section mentions 20 only as the number estimated to be needed for statistical power. This source does not report BRAVE Self-Help effect sizes, so it cannot establish the relative-size comparison. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn the only existing implementation trial for childhood anxiety, Jolstedt et al reported an average adherence of 6 of 12 modules, with only half of the sample reaching module 4, despite the presence of therapist assistance and parent involvement.
“Furthermore, in the only existing implementation trial for childhood anxiety, Jolstedt et al [15] reported an average adherence of 6 of 12 modules, with only half of the sample reaching module 4, despite the presence of therapist assistance and parent involvement.”
From Large-scale dissemination of internet-based cognitive behavioral therapy for youth anxiety: Feasibility and acceptability study (2018) · cites this paper as [15]
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Experimental — accuracy not yet measuredJolstedt et al reported an effect size of Cohen d=1.22 on the full Spence Children's Anxiety Scale from pre- to posttreatment, with substantial therapist support, parent involvement, and encouragement to log in at least twice a week.
“In their study, the authors reported an effect size of Cohen d=1.22 on the full Spence Children’s Anxiety Scale from pre- to posttreatment, although it should be noted that this intervention was (1) delivered with substantial therapist support (regular asynchronous contact through messages, comments on activities, and phone calls), (2) required both parents and children to complete sessions before”
From Large-scale dissemination of internet-based cognitive behavioral therapy for youth anxiety: Feasibility and acceptability study (2018) · cites this paper as [15]
Access to CBT is limited for adults and children due to factors such as high cost of treatment, long waiting lists, and lack of therapists in rural areas.
“However, both for adults and children, access to CBT is limited, due to factors such as high cost of treatment, long waiting lists, and lack of therapists in rural areas (Jolstedt et al., 2018).”
From Transitioning from face-to-face treatment to iCBT for youths in primary care – therapists' attitudes and experiences (2020) · cites this paper as Jolstedt et al., 2018
iCBT for youths is still considered to be in a developmental phase regarding implementation.
“However, iCBT for youths is still considered to be in a developmental phase regarding implementation (Jolstedt et al., 2018).”
From Transitioning from face-to-face treatment to iCBT for youths in primary care – therapists' attitudes and experiences (2020) · cites this paper as Jolstedt et al., 2018
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References 47 · Cited by 75
- Authors
- Jolstedt, M., Ljótsson, B., Fredlander, S., Tedgård, T., Hallberg, A., Ekeljung, A., Högström, J., Mataix-Cols, D., Serlachius, E., & Vigerland, S.
- Affiliations
- Region Stockholm (SE)
- Karolinska Institutet (SE)
- Region Jämtland Härjedalen (SE)
- Corresponding author
- Jolstedt, Maral
- Venue
- Internet Interventions
- Publisher
- Elsevier BV
- Published
- 2018-06
- Volume
- 12
- Pages
- 121-129
- ISSN
- 2214-7829 (ISSN-L)
- PMC
- PMC6096323
- OpenAlex
- W2767764952
- Cited by
- 75
- References
- 47
- Citations by year
- 2026: 5 · 2025: 6 · 2024: 5 · 2023: 2 · 2022: 4 · 2021: 41 · 2020: 4 · 2019: 4 · 2018: 4
- FWCI
- 3.76
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Internet Interventions (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Swedish Research Council for Health, Working Life and Welfare (Forte 2014-4052)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- internet-based cognitive behavioral therapy, childhood anxiety disorders, rural health care, treatment feasibility, access to mental health care, treatment satisfaction, functional disability, maintenance of treatment effects
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