Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder.

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.

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial.

Importance: Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited. Objective: To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT). Design, Setting, and Participants: This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study. Interventions: ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist. Main Outcomes and Measures: The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs. Results: Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group. Conclusions and Relevance: In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD. Trial Registration: ClinicalTrials.gov Identifier: NCT03247075.

Visual attention to emotional faces in adolescents with social anxiety disorder receiving cognitive behavioral therapy.

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.

Therapist-guided internet-delivered cognitive-behavioural therapy supplemented with group exposure sessions for adolescents with social anxiety disorder: a feasibility trial.

OBJECTIVES: Social anxiety disorder (SAD) is one of the most common psychiatric disorders in youth, with a prevalence of about 3%-4% and increased risk of adverse long-term outcomes, such as depression. Cognitive-behavioural therapy (CBT) is considered the first-line treatment for youth with SAD, but many adolescents remain untreated due to limited accessibility to CBT. The aim of this study was to develop and evaluate the feasibility and preliminary efficacy of a therapist-guided internet-delivered CBT treatment, supplemented with clinic-based group exposure sessions (BIP SOFT). DESIGN: A proof-of-concept, open clinical trial with 6-month follow-up. PARTICIPANTS: The trial was conducted at a child and adolescent psychiatric research clinic, and participants (n=30) were 13-17 years old (83% girls) with a principal diagnosis of SAD. INTERVENTION: 12 weeks of intervention, consisting of nine remote therapist-guided internet-delivered CBT sessions and three group exposure sessions at the clinic for the adolescents and five internet-delivered sessions for the parents. RESULTS: Adolescents were generally satisfied with the treatment, and the completion rate of internet modules, as well as attendance at group sessions, was high. Post-treatment assessment showed a significant decrease in clinician-rated, adolescent-rated and parent-rated social anxiety (d=1.17, 0.85 and 0.79, respectively), as well as in general self-rated and parent-rated anxiety and depression (d=0.76 and 0.51), compared with pretreatment levels. Furthermore, 47% of participants no longer met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for SAD at post-treatment. At a 6-month follow-up, symptom reductions were maintained, or further improved, and 57% of participants no longer met criteria for SAD. CONCLUSION: Therapist-guided and parent-guided internet-delivered CBT, supplemented with a limited number of group exposure sessions, is a feasible and promising intervention for adolescents with SAD. TRIAL REGISTRATION NUMBER: NCT02576171; Results.