Working mechanisms in cognitive behaviour therapy for child anxiety disorders

Rationale: Anxiety disorders are common youth psychiatric disorders, and cognitive behavioural

therapy (CBT) is the most efficacious treatment for anxiety disorders in children. Nevertheless, about

one third of the children is not anxiety free after treatment. This study aims to examine the working

mechanisms in child anxiety treatment. In particular, the influence of the therapist-child alliance on the

efficacy of child CBT will be examined. This study is an innovative study into the effects of therapist

feedback in child CBT.

Method: 130 Children and adolescents referred to mental health clinics are treated with a new

version of the CBT manual “Discussing + Doing = Daring”, incorporating cognitive therapy, behavioral

therapy, and mindfulness. Children are randomly assigned to either the ‘therapist feedback group’ or

the control group (without therapist feedback). At pre-, mid-, post-, and 10 weeks follow-up treatment,

children and parents complete a questionnaire measuring the child’s anxiety symptoms and child-

therapist alliance. On a session-to- session basis, children and parents assess their treatment

satisfaction, child daily functioning, and child anxiety symptoms. Feedback on these last three topics

was provided to the therapists in the feedback group.

Implications: Data will be analyzed using innovative statistical techniques (i.e. multilevel modeling,

mediation models). Results will contribute to a better understanding of the working mechanisms in

child anxiety treatment. For example, if some factors have a positive or negative influence on

treatment efficacy, the treatment could be adapted to specific target groups or to specific elements.

Clinical implications will be discussed regarding the influence of the therapist-child alliance on CBT

and whether assessing and using therapist feedback on a session-to- session base is useful.

The following working mechanisms are explored in this study:
1. Child factors (gender, age, comorbidity)

2. Parental factors (psychopathology, support, involvement)

3. Therapist factors (education, experience, alliance)

4. Therapy ingredients (feedback, CBT modules)

In addition, it will be examined which child needs basic or specialized mental health care (based on the Dutch system)

For all participants, four assessments are conducted: Pre intervention, Halfway intervention, Post intervention, Follow up (after 10 weeks).

Next to these four assessments, all participants fill out a short questionnaire after each session.

Cognitive behavioural therapy (CBT): modular version of individual CBT: Discussing + Doing = Daring (Bögels, 2008). Therapy consists of 8 modules and the therapist is free to choose which modules he or she will apply. An exception is made for the first session, this has to be psychoeducation, and the last session of therapy has to be a summary and prevention of relapse. Main ingredients of the modules are: psycho-education, cognitive restructuring, mindfulness, exposure, coping, behavior experiments, prevention of relapse, and parent guidance.



Feedback informed treatment

All children receive CBT as described above. When therapy starts, children are divided into two groups: feedback or non-feedback. In the feedback group, therapists receive feedback from the measures that parents and children fill out after every session: treatment satisfaction, daily functioning, and anxiety symptoms. Therapists are asked to discuss this feedback with the child in the next session.
Children in the non-feedback group also fill out these measures, but their answers are not send to the therapist.