Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways ...to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.
Sixty-seven adolescents (12–17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.
In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = −4.53, z = −3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19–1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00–2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.
Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases.
Clinical trial registration information—Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631.
Autism spectrum disorder (ASD) and social anxiety disorder (SAD) have partly overlapping symptoms. Gaze avoidance has been linked to both SAD and ASD, but little is known about differences in social ...attention between the two conditions. We studied eye movements in a group of treatment-seeking adolescents with SAD (
N
= 25), assessing SAD and ASD dimensionally. The results indicated a double dissociation between two measures of social attention and the two symptom dimensions. Controlling for social anxiety, elevated autistic traits were associated with delayed
orienting to
eyes presented among distractors. In contrast, elevated social anxiety levels were associated with faster
orienting away
from the eyes, when controlling for autistic traits. This distinction deepens our understanding of ASD and SAD.
To evaluate if an internet-delivered parent training program is noninferior to its group-delivered counterpart in reducing child disruptive behavior problems (DBP).
This noninferiority randomized ...clinical trial enrolled families seeking treatment in primary care in Stockholm, Sweden, for DBP in a child 3-11 years of age. Participants were randomized to internet-delivered (iComet) or group-delivered (gComet) parent training. The primary outcome was parent-rated DBP. Assessments were made at baseline and 3, 6, and 12 months. Secondary outcomes included child and parent behaviors and well-being and treatment satisfaction. The noninferiority analysis was determined by a one-sided 95% CI of the mean difference between gComet and iComet using multilevel modeling.
This trial included 161 children (mean age 8.0); 102 (63%) were boys. In both intention-to-treat and per-protocol analyses, iComet was noninferior to gComet. There were small differences in between-group effect sizes (d = −0.02 to 0.13) on the primary outcome with the upper limit of the one-sided 95% CI below the noninferiority margin at 3-, 6-, and 12-month follow-up. Parents were more satisfied with gComet (d = 0.49, 95% CI 0.26, 0.71). At 3-month follow-up, there were also significant differences in treatment effect on attention-deficit/hyperactivity disorder symptoms (d = 0.34, 95% CI 0.07, 0.61) and parenting behavior (d = 0.41, 95% CI 0.17, 0.65) favoring gComet. At 12-month follow-up, there were no differences in any outcomes.
Internet-delivered parent training was noninferior to group-delivered parent training in reducing child DBP. The results were maintained at 12-month follow-up. This study supports internet-delivered parent training being used as an alternative to group-delivered parent training in clinical settings.
Randomized Controlled Trial of Comet via the Internet or in Group Format; https://www.clinicaltrials.gov/; NCT03465384.
•We examined pupil dilation to emotional faces in adolescent with social anxiety disorder (SAD).•SAD was characterized by an atypical time course of the pupil dilation response compared to healthy ...controls.•I Larger pupil dilation to happy faces at baseline predicted worse outcome of cognitive behavioral therapy.
Atypical attention to potential social threats, such as emotional faces, may be one of the core mechanisms underlying social anxiety disorder (SAD). Pupil dilation is an index of locus coreuleus-noradrenergic activity, and closely linked to attention. In the present study, pupil dilation was studied in adolescents with SAD (N = 26; 22 Female) before the onset of a 12-week cognitive behavioral treatment, and in healthy controls (N = 23). Stimuli were faces with angry or happy emotional expressions. Contrary to our hypothesis, the SAD group did not show hyper-responsiveness to angry compared to happy faces. Instead, an atypical time course of the pupil dilation response was found, resulting in an attenuated response during late time stages. Larger pupil dilation amplitude to happy faces before treatment was related to worse treatment response. These results contribute significantly to our understanding of the mechanisms underlying adolescent SAD.
Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that ...may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.
•Moderators of outcome in Internet treatment for social anxiety disorder in youth was evaluated.•Youth with co-morbid depression symptoms improved more in CBT than in control treatment.•More post-event processing and other maintaining factors predicted reduction of social anxiety.•Demographic variables and social anxiety severity did not predict or moderate the outcome.
Parent training is an effective treatment for disruptive behavior problems in children. However, as there is limited access to traditional face-to-face treatment, other delivery formats have been ...evaluated. This study aims to evaluate possible predictors and moderators of outcome, completion and engagement in parent training when delivered in group or through the internet. A recent randomized controlled non-inferiority trial (N = 161) demonstrated equal effectiveness of the parent training program Comet when delivered in group (gComet) and through the internet (iComet). Demographic, clinical and theory-driven variables were studied to find predictors and moderators of treatment effect, completion and engagement. Linear mixed effects models were used to determine predictors and moderators of change in disruptive behavior from baseline to the 3- and 12-month follow-up. Most variables did not have significant predictive or moderating effects. However, there were some variables that predicted or moderated outcomes that may have implications for practice (e.g., comorbid emotional problems, preferred treatment format, and ADHD). This trial can contribute to guiding clinical work with children with disruptive behavior and results indicate that parent training in both treatment formats can be offered regardless of a range of demographic and clinical factors. Taking patients' treatment preferences into account can increase treatment completion.
The current study evaluated the efficacy of an Internet-based parent-training program for children with conduct problems. Dose–response ratio and costs for the program were also considered.
Parents ...of 104 children (aged 3–12 years) were randomly allocated to either parent training or a waitlist control condition. Diagnostic assessment was conducted at baseline and parent ratings of child externalizing behaviors and parent strategies were completed before and after treatment and at 6-month follow-up.
At post-treatment assessment, children whose parent(s) had received the intervention showed a greater reduction in conduct problems compared to the waitlist children. Between group intent-to-treat effect sizes (Cohen’s d) on the Eyberg Intensity and Problem scales were .42 and .72, respectively (study completers .66 and 1.08). In addition, parents in the intervention group reported less use of harsh and inconsistent discipline after the treatment, as well as more positive praise. Effects on behavior problems were maintained at 6-month follow-up.
The results support the efficacy of parent training, administered through Internet, with outcomes comparable to many of the group-based parent training programs. The efficacy, low cost, and higher accessibility make this intervention a fitting part in a stepped-care model.
► RCT of Internet-based Parent Training for conduct problems. ► Treatment leads to significant reduction in child conduct problems. ► Parents use less harsh, inconsistent discipline and more praise and incentives after treatment. ► Outcomes are comparable to group-based parent training programs. ► Main outcomes remained at 6-month follow-up.
•Youth with social anxiety often perceive eye contact as aversive and avoid it.•We examined the mechanisms underlying this phenomenon.•Youth with SAD were primed to look at either the eyes or mouth ...of faces.•Individuals with SAD shifted their gaze slower from eyes than healthy controls.•Impaired disengagement from eyes may contribute to the experience of eye contact as aversive.
Social anxiety disorder (SAD) is linked to atypical attention to other's eyes. Empirical literature about this phenomenon in childhood and adolescence is scarce. Previous studies in adults have suggested that SAD may be characterized by either rapid avoidance of eye contact, or by impaired shifting of attention away from eyes once eye contact has been established. SAD has also been linked to quick orienting towards eyes, indicating vigilant monitoring of perceived threat.
In the largest eye-tracking study of youth with SAD to date, 10 to 17 year-olds with SAD (n = 88) and healthy controls (n = 62) were primed to look at either the eyes or the mouth of human faces. The latency and likelihood of a first gaze shift from, or to the eyes, was measured.
Individuals with SAD were slower to shift their gaze away from the eye region of faces than controls, but did not differ in orienting toward eyes.
Participants were assessed once after the onset of SAD symptoms, meaning that the longitudinal predictive value of delayed gaze shifts from others’ eyes could not be examined.
Youth with SAD may be impaired in shifting attention from other's eyes. This could contribute to the experience of eye contact as aversive, and may be a maintaining factor of childhood SAD.
Social anxiety disorder (SAD) is a psychiatric condition that often onsets in childhood. Cognitive models underline the role of attention in the maintenance of SAD, but studies on youth populations ...are few, particularly those using eye tracking to measure attention. Cognitive behavioral therapy (CBT) for SAD includes interventions targeting attention, like exposure to eye contact, but the link between CBT and attention bias is largely unexplored. This study investigated attention bias in youth with SAD and the association with outcome from CBT. Latency to attend to pictures of faces with different emotions (vigilance) and latency to disengage from social stimuli (avoidance) was examined in N = 25 adolescents (aged 13-17) with SAD in relation to treatment outcome. Vigilance was operationalized as the time it took to relocate the gaze from a central position to a peripherally appearing social stimulus. The latency to disengage from a centrally located social stimulus, when a non-social stimulus appeared in the periphery, was used as a proxy for avoidance. Attention characteristics in the SAD group were compared to non-anxious (NA) controls (N = 22). Visual attention was measured using eye tracking. Participants in both the SAD and NA groups were vigilant towards angry faces, compared to neutral and happy faces. Similarly, both groups disengaged attention faster from angry faces. Adolescents with SAD who disengaged faster from social stimuli had less social anxiety after CBT. The results indicate that anxious youth display a vigilant-avoidant attention pattern to threat. However, partly inconsistent with previous research, the same pattern was observed in the NA group.
Internet-delivered cognitive behaviour therapy (ICBT) is emerging as a powerful tool to fill the gap between demand and availability of evidence-based treatment for paediatric anxiety disorders. ...However, it is still unclear how to best implement it in routine clinical care. 123 children (8–12 years) with anxiety disorders underwent a 12-week ICBT programme with limited therapist support. Participants were assessed 3- and 12-month post-ICBT (3MFU and 12MFU, respectively). Non-remitters who still fulfilled diagnostic criteria for their principal anxiety disorder at 3MFU were offered additional manualised “face-to-face” (F2F) CBT. The aim of the study was to emulate a stepped-care model of health care delivery, where the long-term treatment gains of ICBT as well as the potential benefit of proving addition treatment to non-remitters of ICBT were evaluated. Remitters of ICBT (
n
= 73) continued to improve throughout the study period (pre-ICBT to 12MFU; Cohen’s
d
= 2.42). At 12MFU, 89% (
n
= 65) were free from their principal anxiety disorder. Of all the participants classed as non-remitters at 3MFU (
n
= 37), 48.6% (
n
= 18) accepted the offer to receive additional F2F CBT. These participants also improved with a large effect from pre-ICBT to 12MFU (Cohen’s
d
= 2.27), with the largest effect occurring during F2F CBT. At 12MFU, 83% (
n
= 15) were free from their principal anxiety disorders. The majority of non-remitters declining additional F2F CBT (63.2%;
n
= 12) did so due to already receiving treatment at their local CAMHS, prior to 3MFU. The effects of ICBT for anxiety disorders are durable at least up to 1 year after the end of treatment. Patients who fail to fully benefit from ICBT improved further with additional F2F sessions at our clinic, suggesting that it may be feasible to implement ICBT within a stepped-care model of health care delivery.
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