Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: Systematic review and meta-analysis

Highlights

• CBT, delivered via online programmes is effective for child anxiety disorders.

• Children and their families found CBT online programmes acceptable and satisfactory.

• The domain will benefit from more randomised controlled trials with follow-ups.

• Future studies should include health economic evaluation of delivering CBT online.

Abstract

Aim

To conduct a systematic review and meta-analysis of the literature to assess efficacy of internet-delivered cognitive behavioural therapy (CBT) for child anxiety disorder.

Method

A systematic search of 7 electronic databases was conducted to assess CBT intervention for children with anxiety problems with remote delivery either entirely or partly via technology. Six articles reporting 7 studies were included.

Results

The findings together suggested that CBT programmes involving computerised elements were well received by children and their families, and its efficacy was almost as favourable as clinic-based CBT. The mixture of children and adolescents included the studies, diverse range of programmes, and lack of consistency between study designs made it difficult to identify key elements of these programmes or draw conclusions on the treatment efficacy.

Conclusions

Analysis supports online delivery for wider access of this evidence-based therapy. Areas in need of improvement for this new method are indicated.

Introduction

Over the last decade, there has been accumulating evidence that cognitive behavioural therapy (CBT) provides effective treatment for children with depression and anxiety. Indeed, both group and individual sessions have been shown to offer sustained benefit for children and youth with such problems (Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004). Anxiety disorders are the most common psychological problem of childhood, with life-time prevalence of approximately 20% (Cartwright-Hatton, McNicol, & Doubleday, 2006). Its negative impact on academic performance, as well as social and emotional development in childhood, and morbidity with other forms of psychopathology (Achenbach, Howell, McConaught, & Stranger, 1995), has been well documented, including a poor prognosis into adulthood (Kendall, Safford, Flannery-Schroeder, & Webb, 2004). Despite the need highlighted above, it has been suggested that as high as 80% of children with anxiety disorders do not receive treatment (Essau, Conradt, & Petermann, 2002).

A number of factors contribute to this difficulty under the UK's National Health Services and health care systems elsewhere, including Australia and USA. At the root of these barriers seems to be the availability of qualified therapists (Weisz, Hawley, & Jensen-Doss, 2004), and issues that stem from this, including time and cost demands for the families or their lack of knowledge leading to failure to identify a problem in need of treatment (March, Spence, & Donovan, 2009).

CBT has been suggested to be suitable for remote administration for its highly structured content (Anderson, Jacobs, & Rothbaum, 2004). Together with the use of recent development in technology (e.g., palm-held devices, DVDs, CD-ROMS, interactive communication systems), research has shown success in delivering CBT in such a manner in adult populations (for reviews see Griffiths and Christensen, 2011, Katlenthaler et al., 2004). A recent review found that a range of programmes with differing levels of clinician input are effective and generally with high adherence rates (Christensen, Batterham, & Calear, 2013). Currently available means to receive CBT includes bibliotherapy (self-help books with or without therapist contact) or programmes using internet and computer. While computer-assisted programmes combine face-to-face clinic sessions with remotely administered online sessions, online CBT programmes are stand-alone with only remote contact with clinicians or educated but non-specialist ‘coaches.’

Thus the evidence would suggest that places such as Scotland with rural and remote areas should consider promoting the use of online or computer-assisted CBT, and NHS-approved computer-based CBT programmes. A recent Scottish report found however, that despite the availability of necessary computer software, there was lack of dedicated patient computers. In addition, there was limited flexibility in offering a personally tailored communication method for patients (Kenicer, McClay, & Williams, 2012). The challenge appears to be one of policy, and extra resources, to deliver this proven mode of treatment.

The literature on online interventions and e-health also illustrates that online treatments include features that are perceived as both having advantages and disadvantages by their users. For example, while anonymity and convenience are welcomed by some users (Christensen et al., 2013), these are disliked as impersonal or perceived as work-like rather than therapeutic, leading to low motivation in others (Schneider, Foroushani, Grime, & Thornicroft, 2014). More discrete barriers have been suggested as visual impairment, poor IT provision, low educational levels (Waller & Gilbody, 2009), as well as patient level of hopelessness (MacLeod, Martinez, & Williams, 2009). The literature also seems to agree that guidance and support, whether the intervention is provided remotely or in person, is essential for the successful outcome (Gellatly et al., 2007). As well, a recent study reports that female and healthy adults were more likely to insist on the standards of online security and privacy of e-health in the home environment (Wilkowska & Ziefle, 2012), suggesting that there may be different levels of understanding and confidence in the domain amongst us, including those at whom intervention programmes are aimed. It seems that patient characteristics and symptom profiles require extra care in identifying suitable patients for this method of treatment.

Research on whether such methods may be effective for childhood anxiety, lags behind that for adult populations. It is possible that online treatment offers a unique advantage over clinic-based programmes. If successful, online CBT treatment addresses the barriers of CBT provision outlined earlier. It may also provide a relief for social stigma to which children and their families may be susceptible. According to a recent report, European children aged 9–16 spend on average 88 min per day online (Livingstone, Haddon, Görzig, & Ólafsson, 2011) and that the use of internet and computers are “thoroughly embedded in children's lives” (p 2, Livingstone et al., 2011). A treatment delivered online may therefore be accepted readily by children for their interests and skills in computing. In addition, an effective, evidence-based therapy delivered online will have the potential to save in therapist cost and time.

A recent systematic review on computer-assisted CBT for child and adolescent anxiety found that all the 10 studies reviewed reported reductions in anxiety and were generally well received by the participants (Richardson, Stallard, & Velleman, 2010). The aim of this review is to examine the evidence on the effectiveness of both online and computer-assisted CBT programmes for child anxiety disorder. Different treatment programmes are available for children and adolescents to accommodate the significant changes in social and cognitive development across childhood and adolescence (e.g., see Kendall, Khanna, Edson, Cummings, & Harris, 2011). Therefore there is a need to conduct a review focusing on pre-adolescent children. The aim was to present the latest range of all programmes involving computer (i.e., online and computer-assisted) designed for anxious children up to the age of 12.