Study finds digital CBT for children with anxiety delivers on par with traditional methods, lowers costs

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In a recently published study, Dr Lancet Psychiatry, A group of researchers evaluated if digitally enhanced, therapist-supported, parent-led cognitive behavioral therapy (CBT) is a cost-effective and clinically effective alternative to standard care for treating childhood anxiety.

Study: digitally enhanced, parent-led CBT versus usual treatment for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomized controlled trial.  Image credit: Ground Pictures/Shutterstock.comStudy: Digitally enhanced, parent-led CBT versus treatment for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomized controlled trial.. Image credit: Ground Pictures/


Child mental health services worldwide struggle to meet demand, highlighting the need for more accessible care. Digital treatments can significantly expand service capabilities, but their full integration into routine care is pending.

Recognizing the urgency, organizations such as England’s National Institute for Health and Care Excellence (NICE) emphasize the importance of digital solutions for young people’s mental health. Anxiety, affecting a significant portion of the population from childhood, leads to major personal and economic consequences.

CBT, particularly in brief, parent-led formats supported by therapists, offers an effective solution by overcoming barriers to access and directly involving families.

Digital platforms such as Online Support and Intervention (OSI) for children’s anxiety, co-developed with families and therapists, show promise for making effective treatments more accessible. However, further research is crucial to evaluate their cost-effectiveness and potential for widespread use in different clinical contexts.

About the study

The present study was registered and sought to involve a total of 34 participating sites, part of the National Health Service (NHS) or local authority, following a published protocol. These include 73 child mental health teams from NHS trusts and a diverse mix of local authority or voluntary or community sector providers.

Eligibility criteria for children include being 5-12 years old with a primary anxiety disorder, as well as their parents having sufficient English language skills, internet access and willingness to consent.

Exclusions apply to children with certain comorbid conditions or those involving child protection concerns, as well as parents with significant intellectual disabilities or serious mental health problems.

The study acknowledges the unique context of the coronavirus disease 2019 (COVID-19) pandemic, which has forced a rapid shift to remote service delivery, affecting the approach to judging what constitutes “treatment in general.”

Randomization was carefully conducted using a web-based system, ensuring balanced allocation across intervention and control groups, although it was not possible to blind participants to the intervention.

Trial procedures were thorough, with families identified, consented and assessed online, followed by a structured engagement with the treatment process across both arms.

Qualitative interviews were conducted to measure acceptability of OSI Plus therapist support, providing rich insight into participants’ experiences.

The primary outcome focused on the impact of child anxiety on family life, using the Child Anxiety Impact Scale-Parent Report (CAIS-P), with a broad suite of secondary outcomes to capture a broad spectrum of impact.

Results of the study

Between December 5, 2020, and August 3, 2022, 706 families were referred, and of these referrals, 444 families met inclusion criteria, consented, and were equally randomized between the two study arms.

Despite initial planning, only 79% of these participants started their allocated treatment within the scheduled 12-week period after randomization.

At the end of the trial, completion rates for the 14-week and 26-week assessments were 79% and 74%, respectively, in the OSI plus therapist support and treatment as usual groups.

The participant population was predominantly white-British, with a majority of girls compared to boys and a mean child age of 9.20 years. Treatment as usual, consisting primarily of CBT, is often delivered through parents.

Before treatment, parents in both groups had similar expectations about the rational nature and potential success of the intervention. However, parents initially felt more confident in the success of OSI and therapist support.

After treatment, therapists felt more comfortable providing traditional treatment than OSI, expressing ambivalence about the future use of OSI, largely due to its novelty and their temporary access during testing.

The study found that OSI plus therapist support was non-inferior to traditional treatment across all primary and secondary outcomes, with minimal differences in efficacy. This was consistent across different sensitivity analyses.

Furthermore, there was little difference in utility scores and quality-adjusted life years (QALYs) between groups.

However, the OSI plus therapist support arm showed lower associated costs, primarily due to shorter delivery times. Despite some uncertainty, cost-utility analyzes have suggested that OSI plus therapist support may be cost-effective in certain circumstances.

Health economic outcomes revealed minor differences in treatment and resource utilization outcomes, suggesting potential cost-effectiveness of OSI plus therapist support with noted uncertainties.

Despite these uncertainties and the absence of serious adverse events, the trial highlighted the potential of OSI plus therapist support as an effective and potentially more efficient alternative to traditional treatment methods for children’s anxiety problems.

This finding underscores the value of exploring more digitally enhanced treatments within child mental health services.

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