The Treatment of Child Anxiety Disorders Using Online Cognitive-Behavioural Therapy: An Investigation of Family Factors and Treatment Compliance as Predictors of Child Treatment Outcome

Abstract

Anxiety disorders are amongst the most common psychological concerns of childhood and adolescence (Cartwright-Hatton et al., 2004). Whilst cognitive-behavioural therapy has been established as an efficacious treatment, only a small proportion of children with anxiety disorders receive help from mental health professionals (Essau et al., 2000). In recent years, there has been growing interest in using the Internet as a mechanism for delivering psychological services. Although initial investigations of online treatment for child anxiety disorders have produced similar results to that of clinic-based treatment, there remains a proportion of children who do show recovery following treatment. By identifying predictors of child response to treatment, it is possible that treatment could be tailored to suit the needs of children who may be a risk for poor treatment outcomes. A large body of research exists regarding the role of family factors in the development and maintenance of child anxiety disorders (see McLeod et al., 2007; Wood et al., 2003). If left unchanged following treatment, it is likely that family factors involved in the maintenance of child anxiety will have an adverse effect on child outcome following treatment. Additionally, the absence of direct contact with a therapist in online treatment presents a greater requirement for self-direction on the part of the client. In the case of children, this is likely to signal the need for greater encouragement and involvement from parents, which may be problematic when dysfunctional dynamics exist within the family. As such, compliance with the online treatment may also be an important predictor of child outcome, when treatment is completed in an online format. The aim of the current study was to examine the role of family factors, compliance with treatment, and child characteristics (specifically, age and gender), as predictors of treatment outcome for children receiving online CBT for anxiety disorders. Participants were 156 children, ranging from 7 to 18 years of age (M = 11.92, SD = 2.47), and at least one of their parents. Children were required to present with a primary anxiety diagnosis of either separation anxiety disorder, social phobia, generalised anxiety disorder, or specific phobia, based on a clinical interview, administered by a trained clinician. Children and parents also completed a battery of questionnaires to assess child anxiety symptoms, parent psychopathology, family functioning, parenting behaviours, and parent relationship quality. Eligible families were assigned to a one of the BRAVE – ONLINE programs based on the child‟s age; children aged 7 to 12 years completed BRAVE for Children – ONLINE and children aged 13 to 18 years completed BRAVE for Teenagers – ONLINE. Results indicated that anxiety severity decreased significantly over time, and 66% of children were free of their primary diagnosis at 6-month follow-up. Child treatment compliance (both session compliance and homework compliance) was found to predict child treatment outcome at 6-month follow-up for older children (aged 13 years or older), but not for younger children (12 years or younger). For older children, low treatment compliance was associated with less favourable child outcomes at 6-month follow-up. Parent compliance with the online treatment was unrelated to child treatment outcome, irrespective of child age. A number of significant relationships were also identified between family factors and child outcome following online treatment for anxiety disorders. Higher levels of parent depression or parent stress, and low parent relationship quality, were associated with less favourable child treatment outcomes at 6-month follow-up (on at least one indicator of child outcome), irrespective of child age. Additionally, high levels of parental anxiety were found to be detrimental to treatment outcome for younger children, though not for older children. Furthermore, the effect of family adaptability on child treatment outcome was conditional on child age, such that high family adaptability (i.e. highly flexible in structure) predicted more favourable treatment outcomes for younger children, though was associated with poor treatment response for older children. Finally, the relationship between parent depression and child global functioning at 6-month follow-up, was shown to be mediated by child homework compliance, for children receiving online CBT for anxiety disorders. Specifically, high levels of parental depression were associated with lower child homework compliance, which in turn was predictive of lower child global functioning at 6-month follow-up. These findings can be seen to have important clinical implications for the treatment of child anxiety disorders, particularly in regards to the relationship between family factors and child treatment outcome. It is possible that the inclusion of additional treatment modules aimed at improving problematic family dynamics (e.g. parent anxiety management), may also improve the chances of children achieving successful outcomes following treatment. Given the paucity of evidence in this area, further investigation is needed to allow for greater conclusions to be drawn. A discussion is provided in relation to future research directions, with the aim of expanding upon the findings of the current study.