Optimizing online CBT-interventions for anxious children

Anxiety disorders have a high continuity and have the highest prevalence rate
of psychiatric disorders in children. Cognitive Behavior Therapy (CBT) is an
effective method for intervening in high levels of anxiety. However, children
cannot profit optimally from CBT, because of three barriers . First, only 20 %
of the children with anxiety disorders receive a training or treatment to treat
the disorder. This is due to the accessibility and the availability of
treatment. Second, the working mechanisms of CBT in children have not been
identified. Based on the theoretical models of CBT in adults, children are
offered strategies to change their cognitions (to have less dysfunctional
cognitions) and to reduce avoidance behavior. However, empirical studies on the
working mechanisms of cognitive and behavioral strategies in children are only
limited and incomplete. Third, interventions are not been sufficiently adapted
to suit the specific needs of children, because it is not clear in which
children CBT works well, and in which children CBT works less well. Possibly,
the developmental level of children strongly affects the amount to which
children can profit from CBT.

The current project aims to address the three barriers that obstruct children
from profiting optimally from CBT. For this purpose, an easy accessible,
online, CBT-based training for anxious children (aged 8-13 years) will be
developed and assessed on its efficacy by performing a randomized controlled
trial (barrier 1). It will be examined whether the training sorts its effect
via reducing dysfunctional cognitions and via reducing avoidance behavior
(barrier 2). Finally, the effect of the cognitive developmental level on the
training*s working mechanisms will be stdueid (barrier 3). Both increasing
CBT*s availability for anxious children by offering an online training, and
providing insight into the working mechanisms and elements that affect CBT*s
efficacy, will contribute to the optimalisation of CBT for anxious children.

A longitudinal randomized intervention study

The online training *Learn to Dare!* is based on the paper version of *Learn to
Dare!* (Simon & Bogels, 2014), which is an evidence based low-level
intervention and includes common CBT-elements. The training will be developed
for children aged 8-13 years with an increased level of anxiety, mild or severe
specific phobias or other DSM-5 anxiety disorders of moderate severity. The
entire training will be offered online via an online platform and there will be
no face-to-face meetings. The exposure exercises will be offered via video
examples and written instructions. Communication with the trainer will take
place mainly via e-mail, but can also be offered via a (video) chat function.
*Learn to Dare!* will be offered to individual children, but children can
communicate via a forum if they want to. The training does not contain any
parent sessions. Parents will, however, be informed about the content of the
training and parent will play a role in stimulating the child to continue
taking part in the training.
The therapists who provide the training, will work via standardized
instructions that have been described in detail. They also received several
basic instructions about performing cognitive restructuring and exposure in
children in this age group and with these problems. Suitable trainers are
bachelors or masters in psychology, orthopedagogy, social workers, or teacher
mentors.
The training consists of eight weeks. The child will spend approximately 2
hours per week on this training. The children work on a weekly basis on
exercises, together with their trainer, and also work in the online module
independently. During session 1, the trainer and the child get to know each
other, the child gets an overview of the training and the role of the parent
will be explained in more concrete detail. During session 2, the child and the
trainer decide together which two anxieties will be given attention during the
training, based on the info from the diagnostic interview and questionnaires.
After this, via an automated randomization, it will be decided which anxiety
will be the focus of the first part of the training (exposure) and which
anxiety will be the focus of the second part of the training (cognitive
restructuring). During session 3, the fearful expectations of the child (what
does the child think will happen) of both anxieties will be made explicit. The
trainer strongly supports and directs the child during this process in order to
validly and safely test the child*s fearful expectations. During session 4 and
5, the child practices with its first fear by exposing himself to it. To
promote generalization of what the child will learn, practicing will be done in
different manners and in different contexts. After each exposure, consolidation
of what was learned will be promoted by judging the extent to which the fearful
expectation came true. During session 6 and 7, the child will learn cognitive
restructuring. In session 6, the focus will be on learning general cognitive
restructuring skills: the children will learn how to identify dysfunctional
thoughts and adapt the dysfunctional thought into a functional one. In session
7, the cognitive restructuring techniques will be applied to the child*s second
fear. During session 8 the child and the trainer focus on how to handle
possible future anxieties and attention will be given to saying goodbye to each
other.

Measurements only: 10 hours time investment
Measurements + intervention = 10 + 16 = 26 hours time investment