Increasing access to evidence-based treatment for child anxiety problems: online parent-led CBT for children identified via schools

A Systematic Review of Guided, Parent-Led Digital Interventions for Preadolescent Children with Emotional and Behavioural Problems

Emotional and behavioural problems (EBP) are prevalent amongst children, and guided, parent-led digital interventions offer one method of improving access to effective treatments. This systematic review (PROSPERO: CRD42023484098) aimed to examine the evidence base for, and characteristics of, these types of interventions through a narrative synthesis. Systematic searches were conducted using Medline, EMBASE, PsycINFO, Scopus and Web of Science in January 2024 and February 2025, supplemented with hand searching in March/April 2024 and February 2025. Studies were eligible if they reported outcomes related to preadolescent EBP from a guided, fully parent-led, fully digital intervention. Thirteen studies were eligible, including 2643 children and covering eight interventions (addressing anxiety problems, comorbid anxiety and depression, attention deficit hyperactivity disorder, conduct disorder and disruptive behaviour). Studies included randomised controlled trials and pre-post studies. The QualSyst checklist was used to assess study quality; all studies were rated as good quality. All studies showed statistically significant improvements in the child's symptoms or interference levels, with small to very large effect sizes immediately post-treatment, and at least medium effect sizes by follow-up, suggesting a promising evidence base. A wide range of intervention characteristics were identified, forming a basis for future intervention development for childhood EBP. However, there was a lack of consistency in how information was reported across studies (such as completion rates) and studies lacked information on parent demographics and key intervention details. Further high quality randomised controlled trials for a wider range of EBP are needed to continue building the evidence base.

A Systematic Review of Parental Involvement in Digital Cognitive Behavioural Therapy Interventions for Child Anxiety

Cognitive behavioural therapy (CBT) is an efficacious intervention for child anxiety that has been translated into accessible digital formats, many of which involve parents in treatment. However, the value of parental involvement in treatment is not clearly understood. This systematic review examined characteristics of parental involvement (i.e., format and content of sessions, level of therapist guidance, and parent session compliance) in digital CBT for child anxiety (mean child age ≤ 12 years) and their relation to child outcomes (primary disorder remission, clinician-, parent-, and child-rated anxiety, and global functioning). Systematic searches in CINAHL, Embase, ERIC, PsychINFO, PubMed, and Scopus up to 14th August 2023, and citation searching, identified 27 articles (as 23 studies) assessing 14 interventions. Two were parent-only programmes for 3-6-year-old children, with the remaining being parent-child programmes targeting older children. Parents were actively involved as coaches/collaborators, assisting their children with anxiety management and exposure, and less often as co-clients working on their own difficulties. Benefits of treatment were observed across interventions, except for one, psychoeducation-based programme. Higher remission rates were more frequently observed in interventions delivered in controlled settings, those with fewer parent-only sessions, or those incorporating more parent- or therapist-led exposure sessions. Most studies were conducted with affluent samples, limiting generalisability, and several received a high risk of bias rating. Future research should examine parent and family related mechanisms of change and modify interventions for improved adherence, such as restricting the number of modules parents are required to complete and teaching key therapeutic strategies such as exposure early in the programme.

Protocol for the process evaluation for a cluster randomised controlled trial evaluating primary school-based screening and intervention delivery for childhood anxiety problems

INTRODUCTION

Anxiety problems are prevalent in childhood and, without intervention, can persist into adulthood. Effective evidence-based interventions for childhood anxiety disorders exist, specifically cognitive-behavioural therapy (CBT) in a range of formats. However, only a small proportion of children successfully access and receive treatment. Conducting mental health screening in schools and integrating evidence-based interventions for childhood anxiety problems may be an effective way to ensure support reaches children in need. The Identifying Child Anxiety Through Schools-Identification to Intervention (iCATS i2i) trial involves screening for childhood anxiety problems and offering a brief online parent-led CBT intervention. This paper presents the protocol for the process evaluation of the iCATS i2i trial, which aims to examine the implementation and acceptability of the study procedures, the mechanisms of change and whether any external factors had an impact on procedure engagement or delivery.

METHODS AND ANALYSIS

This process evaluation will use both quantitative and qualitative methods to evaluate the implementation and acceptability of and barriers/facilitators to engagement and delivery of the iCATS screening/intervention procedures. Quantitative data sources will include opt-out and completion rates of baseline measures and usage analytics extracted from the online intervention platform. Qualitative interviews will be conducted with children, parents, school staff, iCATS i2i clinicians and researchers delivering study procedures. The Medical Research Council framework for process evaluations will guide study design and analysis.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University of Oxford Research Ethics Committee (R66068_RE003). Findings from the study will be disseminated via peer-reviewed publications in academic journals, conferences, digital and social media platforms and stakeholder meetings.

TRIAL REGISTRATION

ISRCTN76119074.

Children's involvement in the development and evaluation of parent-focused mental health interventions: a scoping review protocol

OBJECTIVE

This review will i) describe methods used to involve children in the development and/or evaluation of parent-focused interventions to prevent or treat child mental health problems; ii) summarize the perspectives of children or adults about these methods; iii) highlight any reported enablers and barriers; and iv) identify guidance and make recommendations for further research.

INTRODUCTION

Parent-focused interventions (where children are not primarily involved or are excluded) have been implemented to address various child mental health outcomes. However, it is unclear to what extent, and to what end, children have been involved in developing and evaluating such interventions. Engaging children in formative research activities, with or without their parents, has the potential to improve quality and implementation of the interventions.

INCLUSION CRITERIA

Eligible studies will involve children (5-12 years) in the development and/or evaluation of parent-focused interventions aimed at preventing or treating common child mental health problems (eg, anxiety, depression, ADHD, disruptive behavior) delivered in any setting (eg, school, community, home, health facility). Eligible interventions may include one or more psychosocial practice elements targeting behavioral, cognitive, emotional, interpersonal, social, and/or environmental factors implicated in the onset and maintenance of child mental health problems.

METHODS

Comprehensive searches will be conducted in 5 electronic databases (PsycINFO, MEDLINE, CINAHL, Embase, and Scopus). Gray literature will be sourced using Google as well as through searches of key organization websites and via notifications on social media. Only English-language primary studies will be considered. Findings across a range of methodologies will be charted and combined into a narrative synthesis.

REVIEW REGISTRATION

Open Science Framework https://osf.io/x9376/.

Debate: How much should nonspecialists be involved in mental health care for children and young people when resources are limited?

From the barber-surgeons of the Middle Ages to the digitally enabled clinical interventions of today, the role of nonspecialists in delivering accessible health care remains relevant and important. Their contribution in developing and supporting appropriate interventions and care pathways in the community can make a big difference for the overwhelming majority of children and young people with diagnosable mental health conditions who are not eligible for specialist treatment or do not seek help. Even if resources for specialist services were unlimited, there are independent benefits in involving nonspecialists in mental health care, albeit not without limitations and concerns. The natural shift over time in the boundaries of specialisms, the omnipresence and omnipotence of digital media in our lives and the vision of 'no wrong door' for service users, mean that it is not a question of whether, but of how, nonspecialists should be involved. We need to get past the point of considering them just as alternative providers of mental health interventions and services. Instead, they are best placed to protect children and young people's mental health through ubiquitous everyday actions, which counter the negative and maximise the positive elements in current practices, environments and interactions that influence families and communities.

Preliminary efficacy of a transdiagnostic parent-led internet-delivered intervention for children with anxiety and depressive symptoms: a pilot randomized controlled trial

BACKGROUND

There is extensive research indicating that transdiagnostic interventions are effective for adults and children with anxiety and depressive disorders; however, limited research has been conducted on the efficacy of such programs targeting parents of children with anxiety and depressive symptoms delivered via the Internet. This study aims to investigate the preliminary efficacy of a transdiagnostic Internet-delivered intervention for Romanian parents of children with elevated anxiety and depressive symptoms.

METHODS

We conducted a single-blinded pilot randomized controlled trial. Forty-two parents of children with anxiety and depressive symptoms (Mage = 39.79, 78.6% women) from Romania were randomly assigned to one of the two groups, to ParentKIT, an Internet-delivered intervention based on Rational Emotive and Behavioral Therapy (n = 21), or to a delayed treatment condition (waitlist group) (n = 21). ParentKIT consisted of a brief transdiagnostic intervention delivered through nine modules with therapist guidance.

RESULTS

A significant Group by Time effect was found for child emotional problems as reported by parents (Cohen's d = - 0.85) and for parental self-efficacy (Cohen's d = 0.71).

CONCLUSION

A transdiagnostic Internet-delivered intervention addressed to parents of children with elevated anxiety and depressive symptoms is a promising approach. Future research should include blind assessments as well as multiple outcome assessors and investigate the long-term efficacy of the intervention.

TRIAL REGISTRATION

NCT05341297.

Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomised controlled trial

BACKGROUND

Anxiety problems are common in children, yet few affected children access evidence-based treatment. Digitally augmented psychological therapies bring potential to increase availability of effective help for children with mental health problems. This study aimed to establish whether therapist-supported, digitally augmented, parent-led cognitive behavioural therapy (CBT) could increase the efficiency of treatment without compromising clinical effectiveness and acceptability.

METHODS

We conducted a pragmatic, unblinded, two-arm, multisite, randomised controlled non-inferiority trial to evaluate the clinical effectiveness and cost-effectiveness of therapist-supported, parent-led CBT using the Online Support and Intervention (OSI) for child anxiety platform compared with treatment as usual for child (aged 5-12 years) anxiety problems in 34 Child and Adolescent Mental Health Services in England and Northern Ireland. We examined acceptability of OSI plus therapist support via qualitative interviews. Participants were randomly assigned (1:1) to OSI plus therapist support or treatment as usual, minimised by child age, gender, service type, and baseline child anxiety interference. Outcomes were assessed at week 14 and week 26 after randomisation. The primary clinical outcome was parent-reported interference caused by child anxiety at week 26 assessment, using the Child Anxiety Impact Scale-parent report (CAIS-P). The primary measure of health economic effect was quality-adjusted life-years (QALYs). Outcome analyses were conducted blind in the intention-to-treat (ITT) population with a standardised non-inferiority margin of 0·33 for clinical analyses. The trial was registered with ISRCTN, 12890382.

FINDINGS

Between Dec 5, 2020, and Aug 3, 2022, 706 families (706 children and their parents or carers) were referred to the study information. 444 families were enrolled. Parents reported 255 (58%) child participants' gender to be female, 184 (41%) male, three (<1%) other, and one (<1%) preferred not to report their child's gender. 400 (90%) children were White and the mean age was 9·20 years (SD 1·79). 85% of families for whom clinicians provided information in the treatment as usual group received CBT. OSI plus therapist support was non-inferior for parent-reported anxiety interference on the CAIS-P (SMD 0·01, 95% CI -0·15 to 0·17; p<0·0001) and all secondary outcomes. The mean difference in QALYs across trial arms approximated to zero, and OSI plus therapist support was associated with lower costs than treatment as usual. OSI plus therapist support was likely to be cost effective under certain scenarios, but uncertainty was high. OSI plus therapist support acceptability was good. No serious adverse events were reported.

INTERPRETATION

Digitally augmented intervention brought promising savings without compromising outcomes and as such presents a valuable tool for increasing access to psychological therapies and meeting the demand for treatment of child anxiety problems.

FUNDING

Department for Health and Social Care and United Kingdom Research and Innovation Research Grant, National Institute for Health and Care (NIHR) Research Policy Research Programme, Oxford and Thames Valley NIHR Applied Research Collaboration, Oxford Health NIHR Biomedical Research Centre.

Randomized trial comparing standard versus light intensity parent training for anxious youth

OBJECTIVE

To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD).

METHOD

68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition.

RESULTS

Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms.

CONCLUSION

This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample.

TRIAL REGISTRATION

ClinicalTrials.gov Registry: NCT04922502.https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04922502.

Nursing Practice and Telehealth in School Health Services: A Scoping Review

BACKGROUND

The COVID-19 pandemic has propelled the adoption of telehealth in school settings, emphasising the pivotal role of nurses. This review explores the last decade's evidence on telehealth interventions in school nursing practice; Methods: Following Joanna Briggs Institute guidelines, we conducted a systematic search in PubMed, CINHAL, and Web of Science in March 2023. Out of 518 articles across 21 journals, 32 satisfied the review criteria. The selection process rigorously adhered to PRISMA-ScR guidelines for scoping reviews; Results: The results were categorised into three main areas: (a) the purpose of telehealth and intervention strategies, (b) the role of nursing in school-based telehealth practice, and (c) perceived benefits and limitations of school-based telehealth studies. Telehealth interventions encompass health promotion, mental health management, and early diagnosis. School nurses play a multifaceted role, including management, education, and remote monitoring. While telehealth offers advantages like improved health and cost savings, challenges include digital literacy, device access, and costs; Conclusion: This review underscores the crucial role of telehealth in schools for enhancing healthcare delivery in educational settings. However, more empirical evidence is required to specify nurses' contributions to school-based telehealth interventions. Promoting their leadership through stakeholder collaboration is essential. Further research should address challenges and opportunities in school nursing practice, enriching healthcare in educational settings.

Editorial: Control alt delete - technology and children's mental health

With international contributions from Denmark, Peru, Italy, Turkey, Estonia, Russia, Canada, the USA, Australia and the UK, this special issue offers insights and evidence about the technology's ability to act as a force of good and a source of harm for young people's mental health. As we better understand the complex and bidirectional relationship between technology and mental health, we need to move beyond dichotomous narratives about it being good or bad; it is both, depending on how it is used. Collective responsibility across technology companies, researchers, public services and community organisations, parents and the young people themselves can make a difference in the way technology is used to protect and improve mental health.