10.3 PP 52 72 Self-Help Treatment of Childhood Anxiety Disorders

3 Self-Help Treatment of
Childhood Anxiety Disorders

Lauren F. McLellan, Sally Fitzpatrick,
Carolyn Anne Schniering, and Ronald M. Rapee
Overview of the Issue – The Need for Innovation

Despite advances in the development of evidence-based interventions for
child anxiety, dissemination and uptake of these interventions within the community
remain suboptimal. The objective of this chapter is to examine innovative
approaches in the use of self-help interventions for anxiety in children and adoles-
cents. In particular, the evidence base for both bibliotherapy and computer-based
interventions will be reviewed, with a focus on implications for clinicians in their
own practice.
Cognitive behavioral therapy (CBT) is the recommended treatment for pediatric
anxiety disorders (Bennett et al., 2016). However, up to 80 percent of children and
adolescents do not receive any evidence-based treatment for their anxiety (Ebert
et al., 2015; Pennant et al., 2015). Both person-centered and systemic factors have
been identified as contributing to the poor uptake of treatment. Person-centered
barriers that reduce participation in face-to-face treatment include a lack of symptom
awareness or a lack of knowledge in identifying anxiety as a problem (March,
Spence, & Donovan, 2009); reticence to seek help because of the perceived stigma
associated with mental illness or discomfort discussing mental health problems
(Gulliver, Griffiths, & Christensen, 2010); preference for self-help rather than seek-
ing face-to-face treatment, particularly by adolescent populations (Gulliver,
Griffiths, & Christensen, 2010); concerns about confidentiality (Spence et al.,
2016); and a lack of time and loss of hours to participating in core therapeutic
activities (Gulliver, Griffiths, & Christensen, 2010; Stallard et al., 2007). These
challenges can be exacerbated by a range of systemic factors that contribute to the
low engagement in traditional forms of therapy, such as high costs associated with
face-to-face intervention (Ebert et al., 2015); lack of treatment availability or long
wait-lists (Gulliver, Griffiths, & Christensen, 2010; Stallard et al., 2007); and the
limited number and availability of trained CBT therapists (Gunter & Whittal, 2010;
Stallard et al., 2007).
Self-help treatments such as bibliotherapy and the computerization of psycholo-
gical interventions may address obstacles associated with attending traditional forms
of therapy, as well as having the added benefit of relieving the burden on health care
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Self-Help Treatment of Childhood Anxiety Disorders 53
services (Jorm & Griffiths, 2006). Positive outcomes arising from self-help treat-
ments for young people and their families include (Calear & Christensen, 2010;
Ebert et al., 2015; Spence at el., 2016):
• ability to reach a larger and more diverse clientele across a wider geographic area;
• potentially reduced or negligible waiting lists (depending on the level of therapist
involvement required);
• accessibility at any time and place provides greater convenience;
• anonymity / increased privacy for clients;
• reduced stigma associated with meeting a mental health professional in person;
• flexibility in self-direction and self-pacing results in greater user autonomy;
• the appeal of interactivity and visual attractiveness of internet-based programs for
young people.
These benefits are further strengthened by the eagerness of young people to interact
with their world via online modalities (Spence et al., 2016). Self-help interventions
that use internet or mobile applications appear to be an acceptable method of
intervention to young people and an effective way of engaging them in mental health
treatments, and therefore have the potential to treat more children and young people
than face-to-face forms of therapy (Spence et al., 2016). Current research is focused
on understanding the extent to which these forms of therapies are efficacious and
produce long-term improvements in the reduction of anxiety in children and adoles-
cents. Overall, the research evidence suggests that bibliotherapy and computerized
therapy programs are a useful adjunct to the range of services available for anxious
young people.
Description of the Approach to Innovation

Traditionally, CBT has been delivered in person to individuals or groups by
trained therapists. However, the highly structured nature of CBT, ease of manualiza-
tion, and time-limited approach fostered the development of CBT self-help programs
for children and adolescents. Self-help programs vary as to the type of self-help
modality used (bibliotherapy compared to online), the level of guidance provided to
children by their parents, and the extent to which therapist support is provided in
implementing the program.
Historically, attempts to disseminate programs to a wider audience resulted in the
development of self-help programs in which individuals address issues of concern
with the assistance of video materials, audiotapes, or computerized programs
(Rapee, Abbott, & Lyneham, 2006). The most widely developed form of self-help
delivery has been through bibliotherapy, which provides written material to partici-
pants and instructions on how to practice skill development. More recently, the self-
help content delivered in bibliotherapy programs has been adapted to an online
environment. Initially, this involved the delivery of information on CD-ROM and
videos. These programs did not require internet connection and therapist support was
provided via telephone. Technological advances in recent years have seen CD-ROM
54 Anxiety Disorders
programs give way to the development of internet-based therapy programs. Internet-

delivered CBT involves the integration of information technology and psychological
treatment (Vigerland et al., 2016). Online programs are delivered through treatment
modules that may provide written texts, audio and video files, and interactive online
features that enable participants to receive feedback and answers to questions.
Online therapy programs for adults have been shown to be as effective as face-to-
face CBT programs for anxiety disorders (Spence et al., 2016). Vigerland and
colleagues (2016) argue that while the evidence base for online therapy programs
for children is increasing, the generalizability of findings from adult studies to
pediatric populations is influenced by important developmental and practical differ-
ences. Content delivered through either bibliotherapy or online contexts must be
appropriate to the developmental level of the child and take into account their
cognitive ability as well as their reading and comprehension levels. In addition,
outcomes may be influenced by the extent to which parents and children differ in
their willingness to participate and their motivation for change.
Outcomes in bibliotherapy and online programs may also vary in the extent to
which youth receive support in implementing the program. For younger children,
most bibliotherapy and online self-help programs typically involve parents leading
their children through the CBT program and guiding implementation of the CBT
skills in day-to-day life. Benefits of guided parent-delivered CBT include less
therapist contact, fewer resources than standard forms of CBT, and the capacity to
be used in stepped-care models of intervention (Thirlwall, Cooper, & Creswell,
2017). In comparison, research suggests that adolescents require less guidance by
parents or therapists in completing self-help programs and practicing skills on a daily
basis (Spence et al., 2016).
Evidence Base for Self-Help Interventions for Anxiety

This chapter will focus on evaluating the evidence for self-help cognitive
behavioral treatments for youth anxiety that are primarily, although not exclusively,
delivered by written (e.g., book) or technological (e.g., CD-ROM or internet)
mediums rather than by a therapist. An intervention is included in our summary if
most of the program could be completed without direct presentation by, or discussion
with, a therapist. Of course, this does not mean that therapists have no involvement,
and most of the interventions described here include some degree of therapist input.
In some cases, this is quite extensive. The interventions have been grouped into two
broad categories: those where clinical delivery takes place via written material
(bibliotherapy) and those where clinical delivery takes place using technology
(e.g., CD-ROM, computer-assisted program, or internet). Programs with some
therapist contact, whether in-person or using technology (e.g., feedback on electro-
nic worksheets, email, telephone, or videoconferencing), were considered self-help
in this chapter because the therapist contact was not the primary source for delivering
the intervention. Furthermore, we focus on cognitive behavioral interventions
because of their existing evidence base for treating youth anxiety, and review
treatment research where participants initially met criteria for an anxiety disorder
rather than subclinical symptoms or where interventions were aimed at prevention of
anxiety.
Bibliotherapy
Research evaluating the efficacy of reading material for the treatment of childhood
anxiety has somewhat understandably focused on material delivered to parents when
treating children. Yet, interestingly, no research has evaluated the outcomes of
printed material delivered directly to adolescents. Interventions with minimal thera-
pist contact for teenagers have utilized technology, and these will be reviewed later in
the chapter.
The first evaluation of parent-delivered self-help for child anxiety was published
by Rapee and colleagues in 2006 (Rapee, Abbott, & Lyneham, 2006). This rando-
mized controlled trial of 267 6- to 12-year-olds (60 percent male) with a DSM-IV
anxiety disorder (generalized anxiety disorder (GAD), social anxiety disorder
(SoAD), separation anxiety disorder (SAD), specific phobia (SPEC), obsessive-
compulsive disorder (OCD), and panic disorder (PD)) found that providing parents
with the self-help book Helping Your Anxious Child (HYAC; Rapee et al., 2000) led
to almost 20 percent higher diagnostic remission (26 percent) than wait-list (7 per-
cent), but less than completing a face-to-face family CBT group program (61 per-
cent). Results were not always consistent for self-report, parent-report, or therapist
symptom measures. Indeed, bibliotherapy at times demonstrated similar effects to
both group CBT and wait-list, depending on the symptoms measured and/or whether
the analysis involved intent-to-treatment or completer analyses only.
The self-help book HYAC provides information about and practical implementa-
tion strategies for CBT skills that children and parents can use to manage youth
anxiety. In the trial, HYAC was accompanied by a child workbook with activities for
parents and children to complete together. Interestingly, there was no therapist
contact in this initial investigation of bibliotherapy for childhood anxiety and it
remains the only study of pure self-help for youth anxiety.
In an effort to investigate methods to enhance outcomes of parent-led bibliother-
apy for childhood anxiety, various types of therapist contact were provided along
with the HYAC book in a second randomized trial (Lyneham & Rapee, 2006).
Parents of 100 6- to 12-year-old children (51 percent male) with a primary DSM-
IV anxiety disorder (i.e., GAD, SoAD, SAD, SPEC, OCD, and PD) from rural and
remote communities in Australia were randomized to wait-list or one of three
treatment conditions. The treatment material (bibliotherapy, HYAC) was identical
in all three treatment conditions. Across the conditions, however, parents were
allocated to receive either nine brief phone calls from a therapist, nine emails from
a therapist, or they could contact a therapist as many times as they liked via phone or
email during the 12-week treatment period (client-initiated contact). Results indi-
cated that remission of primary anxiety disorder (and all anxiety disorders) was
significantly greater when parents received consistent therapist phone support in
addition to the parent self-help book (90 percent remission of primary anxiety
disorder), compared with either of the other two conditions (respectively, 42 percent
and 39 percent in the email and the client-initiated contact conditions). In this study
all active treatments performed better than wait-list (1 percent remission), and
similar results were found for child- and parent-reported symptom measures, as
well as clinician severity rating scales.
These positive outcomes suggested that bibliotherapy, especially when supported
by some therapist involvement, is a promising method to improve access to treat-
ment. Some additional research has indicated that print-based interventions with
therapist support can provide effects that are similar to those shown by face-to-face
therapist-delivered interventions for DSM-IV anxiety disorders, although sample
sizes in these studies were relatively small (Cobham, 2012; Leong et al., 2009). In the
main outcome trial, Cobham (2012) randomly allocated 55 anxious children aged
7–14 years to three conditions: wait-list, face-to-face therapy, and bibliotherapy.
Somewhat surprisingly, 95 percent of children in the bibliotherapy condition were
free of all anxiety diagnoses immediately following treatment, and this figure was
not significantly different to that in traditional treatment (78 percent), while both did
better than a wait-list control condition (0 percent). A demonstration of the application
of bibliotherapy to primary care settings was shown in a study comparing face-to-face
therapy and therapist-supported, parent-led CBT for child anxiety (specifically, GAD,
SoAD, SAD, SPEC, and OCD; Chavira et al., 2014). Although there was some
suggestion that face-to-face therapy was superior (83 percent remission) to therapist-
supported bibliotherapy (71 percent remission), the difference did not reach statistical
significance with the relatively small sample (N = 48). Finally, in the largest study to
date, data from a trial of stepped care for child anxiety were reanalyzed to allow
comparison between self-help (mostly parent-led bibliotherapy, N = 139, primary
diagnoses of DSM-5 anxiety disorders: SAD, SoAD, GAD, SPEC, other) and tradi-
tional, face-to-face treatment with a therapist (N = 142; Rapee et al., 2017).
Immediately following treatment, 49 percent of children in the self-help condition
were free of all anxiety disorders, which was significantly lower than the percentage of
full remission in the traditional therapy group (66 percent). The key value of self-help
though lay in its ease of delivery. Although it led to slightly less remission, delivery of
self-help took 20 percent of the time that therapists required to deliver the traditional
treatment.
Recent research has begun to evaluate the optimal amount of therapist guidance
required for child-anxiety bibliotherapy. In a large sample (N = 194) of children with
GAD, SoAD, SAD, SPEC, or PD/agoraphobia, Thirlwall and colleagues (2013)
compared the same 8-session parent-guided self-help resource (Overcoming Your
Child’s Fears and Worries: A Self-Help Guide Using Cognitive Behavioural
Techniques by Creswell and Willetts, 2007) with either weekly or fortnightly gui-
dance. Weekly guidance involved four face-to-face sessions and four 20-minute
phone sessions, whereas fortnightly guidance involved two face-to-face and two 20-
minute phone sessions. Primary diagnostic remission and symptom improvement
were superior to wait-list (25 percent) for the weekly guidance group (50 percent) but
not for the fortnightly guidance group (39 percent). However, at 6-month follow-up
both conditions showed continued and similar remission (76 percent vs. 71 percent).
Interestingly, guidance in this study involved some face-to-face sessions, limiting

some of the advantages of self-help treatments, such as the utility of the intervention
among populations unable to easily attend in-person sessions with therapists.
Furthermore, this study excluded children whose parents had their own anxiety
diagnosis or other serious mental health conditions. It is possible that therapist-led
programs or heavily therapist-supported self-help may be required when parents
meet criteria for their own psychopathology. However, further research is necessary
in order to empirically evaluate this contention.
While most research on bibliotherapy for youth anxiety has targeted a range of
common anxiety disorders within transdiagnostic intervention, a small amount of
research has investigated disorder-specific programs. Results from case studies, for
example, Lewis et al. (2015), indicate that disorder-specific bibliotherapy can also
lead to reductions in the relevant disorder. Whether a focused, disorder-specific
intervention will lead to larger effects than more generic, “transdiagnostic” inter-
ventions remains to be seen.
Overall, a small number of randomized controlled trials have evaluated bibliother-
apy for children and none have investigated this treatment delivery method for
adolescents. Among the small body of literature in children, bibliotherapy appears
to be a promising treatment delivery method. That being said, the varying meth-
odologies between studies make it difficult to draw firm conclusions about the
amount and type of therapist guidance that would optimize treatment response.
Future large-scale studies will be required to address this issue. Similarly, the impact
of parent psychopathology needs to be more comprehensively evaluated in future
bibliotherapy studies, particularly when minimal therapist guidance is provided.
Technology-Based Approaches
The initial attempts to evaluate the use of computer-based technology to deliver CBT
for childhood anxiety relied on high levels of therapist involvement. For example,
Spence et al. (2006) evaluated computer-augmented therapy against traditional face-
to-face treatment and wait-list among 7- to 14-year-old anxious youth (N = 72,
primary disorders of GAD, SoAD, SAD, and SPEC). Internet treatment involved five
online sessions for the child and three for the parents, with an additional five child
and three parent group sessions conducted face-to-face in the clinic. Face-to-face
treatment involved 10 group sessions with children and six group sessions with
parents (plus two booster sessions at 1 month and 3 months posttreatment). Not
surprisingly, posttreatment remission was similar in the internet (52 percent) and
traditional (59 percent) conditions and both were better than wait-list (13 percent).
A similar study by Khanna and Kendall (2010) compared computer-assisted
therapy with traditional face-to-face treatment and a computer-assisted education
support (i.e., placebo control) condition with 49 7- to 13-year-old children.
Computer-assisted treatment included six child sessions and two parent sessions
assisted by a therapist in addition to six child sessions spent independently on the
computer. Traditional face-to-face treatment included 12 50-minute individual ses-
sions of manualized CBT, while computer-assisted education support involved 12
50-minute sessions with 30 minutes of therapist contact and 20 minutes of time

playing games on the computer. The computer-assisted intervention resulted in
posttreatment remission of the primary disorder among 70 percent of children,
which was not significantly different from those receiving traditional face-to-face
intervention (81 percent), and both were better than the placebo control (19 percent).
Interestingly, both these studies indicated that computer-assisted therapy could
produce outcomes of similar magnitude to traditional face-to-face therapy. However,
both studies suffered two important limitations to address this question. First, both
computer-assisted therapies included considerable contact with a therapist.
The computer-assisted condition in Spence et al. (2006), in particular, involved
a considerable component of traditional face-to-face therapy for which children
had to attend the clinic. Second, both studies involved relatively small samples,
leading to very low power by which to compare two active treatments. The sample
size of the study by Khanna and Kendall (2010) was especially small with only
around 15 participants per condition.
In an effort to reduce the resources required to deliver effective therapy, some
research has begun to explore treatment provided by means of computer-based
technology with minimal assistance from a therapist. Case studies in children and
adolescents (Cunningham et al., 2008; Spence et al., 2008) provided early evidence
for the potential benefits of CD-ROM (Cunningham et al., 2008; Cool Teens) and
web-based (Spence et al., 2008; BRAVE for Teens) interventions with only minimal
therapist support. Cunningham and colleagues provided five adolescents (14–16
years, four with GAD and one with SAD) with a 12-week (8-module) CBT-based
CD-ROM, which they accompanied with brief biweekly calls from a therapist. After
3 months, 40 percent of the adolescents no longer met criteria for their primary
disorder. Spence and colleagues (2008) reported outcomes from one child with
primary SAD (10 years) and one adolescent with primary SoAD (17 years) who
completed an online CBT program comprising 10 sessions with five additional
sessions for parents, supported by weekly emails from therapists and two phone
calls to the parents and child/adolescent. The online program also sent automated
emails prior to and after each online session. Results suggested reliable change for
the adolescent on most symptom measures and remission of all anxiety disorders (as
well as dysthymia) at posttreatment. For the child, remission of anxiety disorders
occurred by 6-month follow-up but not immediately following treatment and reliable
change was observed on parent- but not child-reported symptoms of anxiety and
internalizing.
A growing number of randomized controlled trials have now been conducted
evaluating computer-based CBT programs for children and adolescents with various
anxiety disorders. Using a sample of 43 14- to 17-year-old adolescents (GAD,
SoAD, SAD, SPEC, OCD, PD), Wuthrich and colleagues (2012) compared an
8-module CD-ROM (Cool Teens) supported by brief (on average 16 minutes)
weekly therapist calls to the teens and three to the parents against a wait-list.
Following treatment there was significantly greater remission of the DSM-IV pri-
mary anxiety disorder (41 percent) among treated adolescents than among those on
wait-list (0 percent). Similar differences were reported on all other measures
reported by both the teenagers and their parents. Spence and colleagues (2011)
evaluated the BRAVE for Teens web-based program comprising modules for both
the adolescents and their parents, which was supported by weekly therapist emails
and a single therapist support call. This internet program with minimal therapist
support was compared to a traditional 10-session clinic program and a wait-list in
a population of 115 anxious adolescents. Teens who demonstrated “moderate” or
“severe” levels of depression were excluded. Treatment (regardless of delivery)
resulted in greater remission of the primary disorder (GAD, SoAD, SAD, or
SPEC; online = 34 percent; traditional = 30 percent) compared to wait-list (4 per-
cent). Continuous measures showed slightly mixed outcomes, although most
revealed larger effects for the two treatment conditions relative to wait-list.
Overall, research evaluating technology-based self-help (with minimal therapist
assistance) for adolescents is promising. The optimal extent of therapist assistance
and the need to include parents still require further research in large randomized
controlled trials.
Research on technology-based self-help CBT programs for children has found less
consistent results. March, Spence, and Donovan (2009) tested the efficacy of their
BRAVE online program by randomizing 73 7- to 12-year-old anxious children (with
primary GAD, SoAD, SAD, or SPEC) to either immediate treatment or wait-list.
Similar to the teen version, the program involved 10 1-hour online lessons for
children and six 1-hour lessons for parents, accompanied by weekly emails from
a therapist to review homework, two therapist support calls with parents and
children, and automated emails prior to and after the availability of each lesson.
The online treatment group (self-help with minimal therapist guidance) failed to
show significantly greater remission of their primary disorder (30 percent) than wait-
list (10 percent). However, greater improvement of active treatment over wait-list
was demonstrated on clinician-rated measures of severity as well as parent- but not
child-rated symptoms of anxiety.
Similar results were found by Vigerland and colleagues (2016) among 93 8- to 12-
year-old anxious children (with primary GAD, SoAD, SAD, SPEC, or PD) who were
randomized to receive immediate treatment or wait-list. Participants were excluded
if they showed high depression (defined as a score of 20 or more on the Child
Depression Inventory (CDI; Kovacs, 1985), or when the primary caretakers them-
selves reported “serious psychiatric disorders” or reported issues related to child risk
or parent substance abuse. Treatment involved an 11-module web-based CBT
program for Swedish children with anxiety (BarnInternetprojektet, BiP). Seven
modules were delivered to parents and four to children. Modules were accompanied
by three telephone calls from a therapist (at the beginning, middle, and end of
treatment) and written feedback by therapists on worksheets and participant ques-
tions lodged onto the web-based platform. Although calls were infrequent, no
information was provided about the length of calls or the time therapists spent
providing feedback on platform worksheets or queries. Following treatment there
was no significant difference in primary diagnostic remission between treatment
(20 percent) and wait-list (7 percent) conditions. However, internet treatment did
show stronger efficacy than wait-list according to clinician-rated disorder severity
and overall functioning and parent-rated (but not child-rated) symptoms of anxiety.
As with the adolescent technology-based self-help literature, more research is
needed to understand the impact of depression comorbidity and parental psycho-
pathology on outcomes, especially when interventions involve minimal therapist
guidance.
One self-help program for preschool-aged children with anxiety disorders (GAD,
SoAD, SAD, or SPEC) has also recently been evaluated. Donovan and March (2014)
utilized online parent modules taken from the BRAVE online program for older
children accompanied by a booklet containing age appropriate examples and expla-
nations for preschool-aged children. This modified program was compared against
wait-list among 52 children aged 3 to 6 years who had clinical anxiety disorders.
There was no significant difference in remission between the active intervention
(39 percent primary diagnosis and 35 percent all diagnoses) and wait-list (26 percent
primary diagnosis and 26 percent all diagnoses), but children in the immediate
treatment group showed greater reductions than those on wait-list in symptoms of
anxiety and clinician-rated disorder severity. One other study holds some relevance
to the current review. Morgan and colleagues (2017) developed an online version of
the Cool Little Kids early intervention program (Rapee, Lau, & Kennedy, 2010) that
involved 8 modules aimed directly at parents. Therapist involvement was minimal,
comprising only automated emails and the availability of telephone support if
requested. Preschool-aged children were included on the basis of anxiety risk due
to high temperamental inhibition and hence this study is not directly relevant to the
current review since the presence of anxiety disorders was not formally assessed
prior to the intervention. However, the children had high levels of pretreatment
anxiety symptoms and the majority probably met criteria for a disorder. Following
intervention, significantly fewer children in the active intervention met criteria for an
anxiety disorder (40 percent) than those on wait-list (54 percent). Parents in active
treatment also reported that their children had fewer symptoms of anxiety and less
life interference than those on wait-list.
While most research on technology-based self-help programs for anxiety has
delivered broad-based anxiety programs (i.e., programs targeting a range of common
anxiety disorders in the same intervention), a small amount of research has investi-
gated disorder-specific programs. A CBT intervention for children with specific
phobia (8–12 years) was evaluated in a small (N = 30) open trial using the previously
described Swedish BiP web-based self-help program with minimal therapist gui-
dance (Vigerland et al., 2013). Results at posttreatment indicated reductions in
clinician-rated severity, remission of specific phobia (35 percent), and improvements
in symptoms on parent and child reports. Furthermore, improvements were main-
tained at 3-month follow-up. However, the lack of a control group and randomization
make it difficult to reach firm conclusions from this study. Finally, only one study to
date has compared disorder-specific intervention against transdiagnostic treatment
for young people aged 8–17 years with social anxiety disorder (Spence et al., 2017).
The SAD-specific online intervention produced similar outcomes (13 percent remis-
sion) to a broad-based anxiety program, BRAVE Online (described previously)
(15 percent remission), immediately following treatment, but both were significantly
better than wait-list (3 percent remission). At 6-month follow-up, both conditions

continued to show improvements (although limited) and did not differ significantly
(specific – 30 percent; generic – 35 percent). Further research using larger rando-
mized trials is required to determine whether disorder-specific self-help interven-
tions might lead to larger effects than transdiagnostic or generic self-help programs.
The empirical evidence for technology-based self-help programs for children and
adolescents with anxiety is not extensive. Among this small body of literature,
variation in the type and extent of therapist involvement and crucial differences in
participant inclusion limit the ability to draw firm conclusions. Most studies also
include relatively small samples and there has been almost no comparison against
placebo. Overall outcomes can at best be described as “promising.” There is some
hint that programs aimed at adolescents may provide more consistent benefits than
those aimed at children, although the number of studies is still too few to draw firm
conclusions. It is possible that the technology-based interventions provide a more
appealing delivery method for this often difficult to engage group of anxious youth.
Research with anxious children has shown treatment benefits on clinician-reported
outcomes, but effects on symptom measures have been less consistent, especially
when looking at children’s reports. Surprisingly, few significant benefits have been
demonstrated on the critical measure of diagnostic remission. Larger studies with
longer-term follow-ups will allow empirical evaluation of the impact of child
severity and parent psychopathology as potential moderators or predictors of self-
help treatments for child anxiety. Studies evaluating technology-delivered interven-
tions without therapist support are required. This is a yet-unanswered empirical
question that has the potential to further improve access to, and cost-effectiveness
of, self-help interventions for anxiety in young people.
Predictors of Change
Predictors of response to treatment have hardly been examined within trials
of self-help for anxious youth since studies in this area to date have been focused on
simply establishing the efficacy of these interventions. One of the logical potential
predictors is age. Given the increased requirements for motivation and maturity
within self-help, it may be expected that adolescents will manage self-help better
than children (Spence et al., 2008). However, in reality, so-called “self-help” for
children often follows a “parent as therapist” model (e. g., Rapee et al., 2006),
whereas adolescents are expected to contribute more directly to their own progress
(e.g., Wuthrich et al., 2012). Hence, it is more likely that children will respond more
extensively to self-help than adolescents, because this form of intervention with
children benefits from an external motivational agent (the parent). Empirically, such
comparisons have not been made. The only empirical examination of the impact of
age on outcomes in bibliotherapy evaluated results from a trial restricted to children
aged 7–12 years (Thirlwall, Cooper, & Creswell, 2017). Within this restricted range
there was no significant impact of age overall on outcome. However, younger
children were more likely to be free of their primary diagnosis at posttreatment
whereas older children showed a more favorable outcome at 6-month follow-up.

The lack of significant impact of age on overall outcome in this study agrees with the
results of a meta-analysis evaluating outcomes from internet programs for youth
anxiety in which age was not identified as a significant predictor of differential
efficacy between studies (Vigerland et al., 2016).
The reanalysis by Thirlwall, Cooper, & Creswell (2017) also examined the impact
of other predictors. The only other significant predictor of outcome was primary
diagnosis – there was no prediction from primary diagnosis to overall outcome,
however, children with a primary diagnosis of GAD had better outcomes at post-
treatment, but worse outcomes at 6-month follow-up. No other variables, including
child gender or comorbidity, significantly predicted outcomes.
Finally, a recent analysis of online delivery of early intervention for inhibited
preschool children showed that treatment outcome was uniquely predicted by parti-
cipants’ (parents’) access to a printer (Morgan, Rapee, Salim, & Bayer, 2018).
In turn, printer access predicted frequency of practice of skills taught in the program
(a potential mediator). Aside from this one indication, at present we have little
understanding of factors that might mediate self-help interventions and especially
those that specifically mediate self-help relative to more generic treatment processes.
We have reached the stage where the basic efficacy of self-help interventions, both
via printed materials and online, has now been established. Therefore, the field
should now be ready to start to evaluate both the predictors of outcome and its
potential underlying mechanisms. What will be particularly interesting will be to try
and distinguish predictors and mechanisms of response to treatment that are general
to all treatments for anxious youth from those factors that are specifically relevant to
self-help delivery.
Clinical Case Illustration

Amelia is a 14-year-old girl who presented to the Centre for Emotional
Health, Macquarie University, Sydney. She had a history of anxiety during childhood
and, when she entered high school, she was overwhelmed by the new range of
socially challenging situations. She felt like an “outcast,” had few friends, and ate her
meals alone. She was too scared to ask teachers for help and was worried about doing
or saying the wrong thing and embarrassing herself. Amelia also “daydreamed” and
found it hard to concentrate on her work. She began to fall behind in her grades and
became increasingly isolated. Amelia experienced escalating distress, sometimes
taking up to three hours to get ready for school due to perfectionism with her hair and
make-up and she was having difficulty keeping up with daily tasks. Increasingly, her
severe anxiety and a range of somatic problems such as stomachaches and headaches
led to absences from school. As the year continued, Amelia experienced periods of
depressed mood, poor self-esteem, and decreased interest in activities she previously
enjoyed. Amelia’s mother was unable to enforce regular school attendance. On days
when Amelia did attend, she often would stay only an hour or two before calling her
mother to collect her. Eventually, Amelia’s distress and avoidance became so severe
Amelia’s symptoms of anxiety and depression.

40
30
20
10
0
Pre treatment Post treatment 6-month follow-up
Spence Children’s Anxiety Scale (Spence, 1998)
Short Moods and Feelings Qre (Angold et al 1995)
Figure 3.1 Amelia’s Symptoms of Anxiety and Depression
that the school counselor recommended that she commence distance education. Her
parents then contacted our clinic for an assessment.
A telephone-based diagnostic assessment, separately with Amelia and her
mother, highlighted avoidance of a range of social and public situations includ-
ing crowds, shopping centers, public transport, starting or joining conversations,
and going to school. When she did attend school, she was quiet and failed to
answer questions in class, didn’t ask teachers for help, and spent the majority of
time alone. These behaviors were underpinned by some extreme beliefs such as
believing that others saw her as “stupid,” having a “mental issue,” or as being
“different.” The interview also picked up a wide range of worries including
concerns about school performance, peer relationships, and family health.
Amelia was quite perfectionistic, and her mother described how she often got
“stuck” for long periods due to her fears of making a mistake. Aside from these
fears, Amelia reported feeling sad most of the time, feeling worthless and guilty,
and having “no energy.” In sum, the information from her interview suggested
that Amelia met criteria for social anxiety disorder (SoAD) as her principal
diagnosis, in addition to generalized anxiety disorder (GAD) and persistent
depressive disorder (PDD). Amelia had recently been prescribed an antidepres-
sant by a psychiatrist; however, she had discontinued medication due to side
effects. There was no evidence of suicide risk, and Amelia had a supportive
family. Questionnaire data on symptoms were consistent with her interview
responses (see Figure 3.1).
Amelia’s family lived in a rural town with minimal access to mental health
services. The family also could not afford to pay for lengthy psychological treatment.
As a result, Amelia received treatment remotely via an online program for comorbid
anxiety and depression in adolescents (i.e., Chilled Plus Online; Schniering et al.,
2017). The program consists of eight modules, which are completed online over
eight weeks, and each module is accompanied by a 30-minute therapist phone call.
Parents receive a printed workbook and three 30-minute phone calls, as well as
phone updates throughout. The content covered in each module is shown in
Table 3.1 Overview of Chilled Plus Online modules

Module Content
1 Understanding Anxiety and Depression
2 Motivation, Goals and Increasing Enjoyment
3 Stepladders 1: Building Goal-Directed Action and Overcoming Avoidance
4 Stepladders 2 and Managing Emotions
5 Realistic Thinking and Stepladders
6 Positive Coping and Stepladders
7 Building Relationships and Stepladders
8 Review, Relapse and Maintenance
Table 3.1. More detail on the program components and the way in which we worked
with Amelia follows.
Engagement and Motivation

A common problem for treatment is noncompletion of modules and lack of between-
session practice. Strategies that have been employed with success in our program to
address this problem include building strong rapport, persistence in phoning the
client until contact is made, working with ambivalence as a mental state to be
explored, and finding a small aspect of the problem to work on using graded steps.
Throughout the program attention is paid to addressing the cycle of low motivation
and avoidance drawing on motivational interviewing and behavioral activation
principles. Adolescents develop goals that are related to their personal values, and
they are taught to work with motivation as a fluctuating state of mind and to focus on
boosting self-confidence with behavioral action. Weekly phone calls as well as text
messages serve as cues for action and, where the youth agrees, parents are recruited
to assist in providing increased structure for activities and rewards for change.
Initial sessions with Amelia focused on establishing rapport, developing
appropriate expectations for the program and her role in it, and creating goals
for change. During the first phone session, it became clear that Amelia had not
completed module 1 online. As a result, sections of the module were completed
with Amelia over the phone and she was asked to finish both modules 1 and 2
before the next phone session. At the second phone call, Amelia still had not
completed either module. The therapist again completed some of module 2 with
her and spent the remainder of the session discussing barriers to completion of
modules and how she might overcome those. Avoidance was a key maintaining
factor for Amelia and she was having difficulty breaking this pattern of avoidant
coping in treatment. Amelia set goals for the program as follows: a) “I want to
feel more relaxed and confident,” and b) “I want to be able to engage
in situations that I am avoiding, in particular social situations.” Time was
spent with her mother brainstorming strategies to facilitate the completion of

modules, including rewards for effort and providing support. At this point it was
decided to allow an extra week between the phone sessions for modules 2 and 3
to allow Amelia to complete the online content for the first three modules. At the
phone call for module 3, Amelia had made good progress and had finished all
online material and commenced practice around pleasant events. Motivational
strategies as described previously were employed at every session thereafter in
order to consolidate gains and to facilitate continued behavioral action.
Building Goal-Directed Action and Reducing Avoidance

Graded hierarchies are used throughout the program to build goal-directed action
in situations that are avoided due to anxiety (e.g., not asking a question in class)
as well as situations that are avoided due to low mood (e.g., withdrawal from
friends). The development of goal-directed action progressed steadily over
modules 3 to 8, and Amelia completed various hierarchies on social situations,
including visiting public places such as restaurants and shopping centers, and
using public transport. Stepladders also included more detailed social behaviors
such as making telephone calls, speaking to her distance education teachers,
engaging in online chat, and starting conversations with staff in stores.
Hierarchies targeting situations related to low mood included developing
increased social contact and friendships, and engaging in new interests and
sport, such as drawing, music, and dance. At the completion of the main
program, Amelia was far less avoidant in her schoolwork by speaking to
teachers on the telephone, asking for help, attending face-to-face workshops
with other students, and initiating online contact with students in her grade.
All hierarchies were closely aligned with her personal program goals.
Managing Negative Emotion and Cognition

In the program, skills for managing negative emotion and cognition are covered
transdiagnostically, such that they can be used to address components of both anxiety
and depression. Emotion regulation skills in treatment include emotion awareness,
the development of greater distress tolerance by having healthy beliefs around
emotion, practicing staying with an emotion until it passes, and refocusing attention
to the task at hand (“emotion surfing”). Amelia stated that the skill of emotion surfing
(especially learning to accept moderate increases in negative emotions while main-
taining her focus on whatever task she was doing) “changed her life” and that she
used this daily as a means of coping with periods of low mood or stress. Realistic
thinking skills are also taught in therapy to challenge both worried and negative
thoughts, using a set of structured steps where adolescents look for “evidence” in
order to challenge their thoughts and develop an alternative more realistic thought.
Amelia was able to successfully challenge worries around schoolwork, and in
particular, worked with her therapist to challenge several beliefs underlying her
low self-esteem.
Building Relationships, Pleasant Events, and Positive Coping

Throughout treatment, depressive mood is targeted via activities that bring pleasure
or mastery, by enhancing relationship skills and interpersonal connectedness, and via
daily self-care (e.g., rest, diet, exercise). For Amelia, enjoyable activities were
commenced in module 2, and continued throughout. Amelia used art as a method
of self-expression and would often do pencil drawings as a means of riding her
feelings out until they passed. Amelia needed help to improve her interpersonal skills
in order to initiate new friendships. Following skill development, increased social
contact assisted in boosting her mood, and at the conclusion of the program she had
regular contact with two old friends with whom she had reconnected. Attention was
also paid to sleep patterns as Amelia was going to bed at 1am and sleeping until
nearly midday, and we worked with Amelia and her mother to establish more regular
sleeping patterns using worry reduction and stimulus control principles.
Comorbidity and Treatment

As with other adolescents with comorbid presentations, one of the challenges we
faced with Amelia was deciding how to treat her complex array of problems given
the constraints of an 8-week program. One way in which we were able to address
multiple problems concurrently was by targeting core common processes under-
pinning anxiety and depression, namely behavioral avoidance and difficulty mana-
ging negative thoughts and feelings. In addition, the focus on motivation and
engagement throughout was essential to therapeutic outcomes. Given the 8-week
time frame of therapy, we were able to address social anxiety and depressed mood;
however, less therapy time was spent treating symptoms of generalized anxiety.
While there was some generalization of treatment effects across disorders, Amelia
would have likely benefited from additional therapy time targeting additional symp-
toms of generalized anxiety disorder.
Posttreatment Outcomes
Amelia rated all program modules and media components positively. She reported that
she “loved working with us” and that “things were really getting better.” Levels of
avoidance had reduced markedly, and her mood had improved extensively. She
reported having much greater energy and motivation to pursue positive activities.
Measures of therapeutic alliance indicated a strong relationship with the therapist, and
Amelia responded well to therapist guidance on exposure tasks. In the final phone call
she stated, “I can’t thank you enough” and “I never would have been able to come this
far without you.” Formal assessment information supported these impressions. At the
end of treatment Amelia no longer met criteria for her pretreatment diagnoses of social
anxiety disorder, generalized anxiety disorder, and persistent depressive disorder,
although some symptoms of anxiety remained (see Figure 3.1).
In summary, this case illustrates the potential efficacy of a brief online intervention
for comorbid anxiety and depression in youth. The program is currently in the final
stages of evaluation and preliminary results indicate good efficacy (Schniering et al.,
2016). This case has also demonstrated some of the benefits of an online format over
traditional approaches in terms of increased accessibility and acceptability for
a population that can be difficult to engage and retain in treatment. In line with the
literature in the field, the case also illustrates the value of therapist involvement, even
for this self-help intervention. Given the lack of engagement with the program early
on, and the need for therapist intervention to boost initial uptake, it seems unlikely
that Amelia would have achieved the outcomes seen here in the absence of therapist
assistance.
Challenges and Future Development

The development and evaluation of self-help interventions for anxious
youth, especially those involving newer technologies, have grown exponentially in
a very short time. There is little doubt that this field will continue to move ahead at
a great rate and that many of the existing questions will be addressed in the coming
years. Compared to only a few years ago, we are already in a position where anxious
young people in many parts of the world can easily access empirically validated
treatments from the comfort of their own homes. As we have seen in the preceding
review, the growing evidence base suggests that these self-help interventions can
lead to marked reductions in anxiety, close to those seen in traditional face-to-face
programs. At present, most of the available programs rely on some therapist involve-
ment and in many cases, this is quite extensive. Evidence suggests that therapist
supported self-help is associated with stronger outcomes than pure self-help.
However, the optimal level of therapist involvement still requires extensive research.
Pure self-help for anxiety has to date only been evaluated with printed materials
(Rapee et al., 2006) and similarly, only studies using printed materials have com-
pared different amounts of therapist support (Lyneham & Rapee, 2006; Thirlwall
et al., 2013). Although mechanisms are unlikely to differ greatly between bibliother-
apy and e-therapy, replication and extension to online programs would be valuable.
Perhaps more importantly, research into the optimal type of therapist support is
lacking. For example, through the advent of technology, a therapist can now be
virtually present during an actual in vivo exposure session. Perhaps a single session
of this type would be more efficacious than several sessions over the telephone, after
the fact. Other aspects of therapist features also need to be evaluated. The optimal
therapist training and qualifications, the types of materials that are best conducted
virtually vs. face-to-face, and optimal means of building a relationship remotely are
all issues that may impact on the efficacy of self-help treatments.
Along these lines, research into other moderators is critically important. Being
able to identify who self-help will work best for and, more importantly, who it may
not work for, will be critical to utilize resources most efficiently. This type of
research requires large samples and may be best achieved through collaborative,
cross-site studies. It is less likely that relevant variables will be the major ones (such
as diagnosis, severity, duration) and more likely that critical moderators will reflect
subtle variables such as the way the individual learns best, the relationship between
parent and child, or simply patient preference. Similarly, research to identify under-
lying mechanisms of change will be critical to improve the efficacy and efficiency of
self-help programs. Change following self-help is very likely to involve many of the
same mechanisms that underpin many therapeutic programs. But there are also likely
to be some unique mechanisms that specifically, or more extensively, mediate change
within self-help delivery. Identification of these processes will be especially
important.
Finally, a fitting way to close this chapter is by briefly examining the role of the
therapist in a future (electronic) world. When e-therapies were first being devel-
oped, many therapists expressed fears and concerns about the future of their
profession. This is less apparent these days but may still sit in the backs of some
therapists’ minds. As we have noted, so-called self-help therapies still work best
when they are supported by therapists. Therefore, far from therapists losing their
jobs, self-help treatments open up new methods of working with clients and new
populations who may never have previously been able to reach a therapist. Hybrid
therapies involving a mix of face-to-face and online sessions may also become
a more common method of treatment. Of course, insurance providers will need to
catch up to fund this mixed model. But there are several aspects of traditional
therapy (such as psychoeducation) that are ideally delivered online and really don’t
require the cost of personal delivery by a highly qualified therapist. Similarly,
virtual technology allows innovations in delivery that were previously unthought
of. We earlier mentioned the possibility of virtual attendance of the therapist during
exposure, but similarly the therapist could be “present” to assist with cognitive
restructuring or relaxation at key times or may be able to provide faster feedback on
monitoring forms. Some of the more experimental methods of treatment, such as
virtual reality exposure or cognitive bias modification, can also be delivered online
(Waters et al., 2016).
Another hybrid method of therapy that is beginning to be very widely discussed is
stepped care. In brief, in a stepped care model, the idea is to begin treatment with the
least costly and involved method and only increase to more resource-intensive
therapy if the patient doesn’t respond. To provide one example of how this might
look, we recently completed a trial of stepped care for anxious young people (Rapee
et al., 2017). After assessment, all youth went into step 1, which consisted of self-
help (equivalent to that described earlier in Rapee et al., 2006 for children and
Wuthrich et al., 2012 for adolescents). Following 12 weeks, they were reassessed
and if they were doing well, that was all they needed. On the other hand, if they
required further treatment, they then progressed to traditional treatment using our
face-to-face, Cool Kids program. Twelve weeks later, following another assessment,
any youth who required even more therapy were progressed to an individual,
formulation-based, intervention with a highly experienced therapist. Using this
model, we were able to produce the same outcomes as in standard, face-to-face
treatment for everyone, but the stepped care model used significantly less therapist
time.
This study was the first to evaluate stepped care for anxious young people and now
paves the way for future research to explore the myriad of variations in the way
a stepped care model could be constructed. These types of ideas potentially herald
a new paradigm for service delivery that will include the optimal mix of self-help and
face-to-face delivery.
Key Practice Points

• Due to recent developments in the field, we are now at a point where we have
a number of evidence-based self-help interventions for anxiety disorders in youth.
• Increased comorbidity, in particular with depression and parental psychopathol-
ogy, may predict poorer treatment response and relapse.
• Due to the limited number of studies available, the role of therapist involvement is
somewhat unclear; however, a limited number of studies suggest that degree of
involvement may influence treatment outcomes.
• Treatment planning in the use of self-help approaches may require joint considera-
tion of client variables (e.g., comorbidity, parental psychopathology), therapist
variables (e.g., therapist preferences, level of expertise), and program character-
istics (e.g., degree of therapist/parent involvement, duration of treatment) to
maximize treatment gains.
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3 Self-Help Treatment of

Childhood Anxiety Disorders

Overview of the Issue – The Need for Innovation

Description of the Approach to Innovation

programs give way to the development of internet-based therapy programs. Internet-

Evidence Base for Self-Help Interventions for Anxiety

Interestingly, guidance in this study involved some face-to-face sessions, limiting

50-minute sessions with 30 minutes of therapist contact and 20 minutes of time

better than wait-list (3 percent remission). At 6-month follow-up, both conditions

whereas older children showed a more favorable outcome at 6-month follow-up.

Clinical Case Illustration

Amelia’s symptoms of anxiety and depression.

Figure 3.1 Amelia’s Symptoms of Anxiety and Depression

Table 3.1 Overview of Chilled Plus Online modules

Engagement and Motivation

spent with her mother brainstorming strategies to facilitate the completion of

Building Goal-Directed Action and Reducing Avoidance

Managing Negative Emotion and Cognition

Building Relationships, Pleasant Events, and Positive Coping

Comorbidity and Treatment

Challenges and Future Development

Key Practice Points

problems in young children: Randomized controlled trial. Journal of the American

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