The Treatment of Child Anxiety Disorders Using Online Cognitive-Behavioural Therapy

348 Pages·2010·2.66 MB·English

by  Samantha Prosser

The Treatment of Child Anxiety Disorders Using Online Cognitive-Behavioural Therapy:
An Investigation of Family Factors and Treatment Compliance as Predictors of Child
Treatment Outcome

Samantha Jayne Prosser
BPsySc (Hons)

School of Psychology
Griffith Health
Griffith University

Submitted in fulfilment of the requirements of the degree
of Doctor of Philosophy

September 2010

Abstract
Anxiety disorders are amongst the most common psychological concerns of
childhood and adolescence (Cartwright-Hatton et al., 2004). Whilst cognitive-
behavioural therapy has been established as an efficacious treatment, only a small
proportion of children with anxiety disorders receive help from mental health
professionals (Essau et al., 2000). In recent years, there has been growing interest in
using the Internet as a mechanism for delivering psychological services. Although
initial investigations of online treatment for child anxiety disorders have produced
similar results to that of clinic-based treatment, there remains a proportion of children
who do show recovery following treatment.
By identifying predictors of child response to treatment, it is possible that
treatment could be tailored to suit the needs of children who may be a risk for poor
treatment outcomes. A large body of research exists regarding the role of family
factors in the development and maintenance of child anxiety disorders (see McLeod et
al., 2007; Wood et al., 2003). If left unchanged following treatment, it is likely that
family factors involved in the maintenance of child anxiety will have an adverse effect
on child outcome following treatment. Additionally, the absence of direct contact with
a therapist in online treatment presents a greater requirement for self-direction on the
part of the client. In the case of children, this is likely to signal the need for greater
encouragement and involvement from parents, which may be problematic when
dysfunctional dynamics exist within the family. As such, compliance with the online
treatment may also be an important predictor of child outcome, when treatment is
completed in an online format. The aim of the current study was to examine the role of
family factors, compliance with treatment, and child characteristics (specifically, age and
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gender), as predictors of treatment outcome for children receiving online CBT for
anxiety disorders.
Participants were 156 children, ranging from 7 to 18 years of age (M = 11.92, SD
= 2.47), and at least one of their parents. Children were required to present with a
primary anxiety diagnosis of either separation anxiety disorder, social phobia,
generalised anxiety disorder, or specific phobia, based on a clinical interview,
administered by a trained clinician. Children and parents also completed a battery of
questionnaires to assess child anxiety symptoms, parent psychopathology, family
functioning, parenting behaviours, and parent relationship quality. Eligible families
were assigned to a one of the BRAVE – ONLINE programs based on the child‟s age;
children aged 7 to 12 years completed BRAVE for Children – ONLINE and children aged
13 to 18 years completed BRAVE for Teenagers – ONLINE.
Results indicated that anxiety severity decreased significantly over time, and
66% of children were free of their primary diagnosis at 6-month follow-up. Child
treatment compliance (both session compliance and homework compliance) was found
to predict child treatment outcome at 6-month follow-up for older children (aged 13
years or older), but not for younger children (12 years or younger). For older children,
low treatment compliance was associated with less favourable child outcomes at 6-
month follow-up. Parent compliance with the online treatment was unrelated to child
treatment outcome, irrespective of child age.
A number of significant relationships were also identified between family factors
and child outcome following online treatment for anxiety disorders. Higher levels of
parent depression or parent stress, and low parent relationship quality, were associated
with less favourable child treatment outcomes at 6-month follow-up (on at least one
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indicator of child outcome), irrespective of child age. Additionally, high levels of
parental anxiety were found to be detrimental to treatment outcome for younger
children, though not for older children. Furthermore, the effect of family adaptability
on child treatment outcome was conditional on child age, such that high family
adaptability (i.e. highly flexible in structure) predicted more favourable treatment
outcomes for younger children, though was associated with poor treatment response
for older children. Finally, the relationship between parent depression and child global
functioning at 6-month follow-up, was shown to be mediated by child homework
compliance, for children receiving online CBT for anxiety disorders. Specifically, high
levels of parental depression were associated with lower child homework compliance,
which in turn was predictive of lower child global functioning at 6-month follow-up.
These findings can be seen to have important clinical implications for the
treatment of child anxiety disorders, particularly in regards to the relationship between
family factors and child treatment outcome. It is possible that the inclusion of
additional treatment modules aimed at improving problematic family dynamics (e.g.
parent anxiety management), may also improve the chances of children achieving
successful outcomes following treatment. Given the paucity of evidence in this area,
further investigation is needed to allow for greater conclusions to be drawn. A
discussion is provided in relation to future research directions, with the aim of
expanding upon the findings of the current study.
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Statement of Originality

This work has not previously been submitted for a degree or diploma in any university. To
the best of my knowledge and belief, the thesis contains no material previously published
or written by another person except where due reference is made in the thesis itself.

Signed: ………………………………………………………………………..

Samantha Jayne Prosser

Date: September 2010

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Table of Contents

Abstract .......................................................................................................................................................... i
Statement of Originality .......................................................................................................................... v
Table of Contents .................................................................................................................................... vii
List of Tables ............................................................................................................................................ xiii
List of Figures ............................................................................................................................................ xv
List of Appendices ................................................................................................................................. xvii
List of Abbreviations ............................................................................................................................. xix
Acknowledgements ............................................................................................................................... xxi

CHAPTER ONE................................................................................................................................................ 1
Childhood Anxiety: Phenomenology, Aetiology, Epidemiology and Treatment ............. 1
Thesis Overview .................................................................................................................................... 1
Phenomenology and Epidemiology of Childhood Anxiety ................................................. 2
Classification of Anxiety Disorders ........................................................................................... 3
Separation anxiety disorder ................................................................................................... 4
Social phobia ................................................................................................................................ 4
Generalised anxiety disorder ................................................................................................. 5
Specific phobia ............................................................................................................................ 5
Obsessive-compulsive disorder ............................................................................................ 6
Posttraumatic stress disorder ................................................................................................ 7
Panic disorder and agoraphobia .......................................................................................... 7
Gender ................................................................................................................................................ 8
Course ................................................................................................................................................. 8
Comorbidity ...................................................................................................................................... 9
Psychosocial Impact ....................................................................................................................... 9
Aetiology of Anxiety Disorders..................................................................................................... 11
Genetic Transmission ................................................................................................................... 11
Temperament/Behavioural Inhibition ................................................................................... 13
Parenting Factors .......................................................................................................................... 15
Parental control ......................................................................................................................... 16
Parental support/rejection .................................................................................................... 19
Parental modelling ................................................................................................................... 21
Negative, Stressful and Traumatic Life Events ................................................................... 22
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Cognitive-Behavioural Treatment of Childhood Anxiety Disorders ............................... 26
Content of Cognitive-Behavioural Treatments .................................................................. 26
The Efficacy of CBT ....................................................................................................................... 28
Inclusion of Parents in Treatment ........................................................................................... 30
Group vs Individual Delivery of CBT ...................................................................................... 31
Service Utilisation .......................................................................................................................... 32
Computerised Delivery of CBT ..................................................................................................... 33
Rationale for Computerised Delivery of CBT with Anxious Youth.............................. 34
Computerised Treatment for Adult Anxiety Disorders ................................................... 35
Computerised Treatments for Youth Anxiety Disorders ................................................ 39
Criticisms of Computerised Psychotherapy ........................................................................ 45
Chapter Summary .............................................................................................................................. 47

CHAPTER TWO ............................................................................................................................................. 49
Childhood Anxiety: Factors Associated with Treatment Outcome ...................................... 49
Chapter Overview .............................................................................................................................. 49
Issues of Measurement when Predicting Treatment Outcome........................................ 50
Family Characteristics ....................................................................................................................... 53
Parent Psychopathology ............................................................................................................ 54
Parent anxiety ............................................................................................................................ 55
Parent depression .................................................................................................................... 59
Parental Stress ................................................................................................................................ 62
Parenting Behaviour .................................................................................................................... 64
Parental control ......................................................................................................................... 65
Parental warmth ........................................................................................................................ 66
Family Functioning ....................................................................................................................... 68
Parent Relationship Quality ....................................................................................................... 72
Family Factors and Computerised Treatments for Child Anxiety ............................... 75
Sociodemographic Characteristics .............................................................................................. 78
Child Age .......................................................................................................................................... 78
Child Gender ................................................................................................................................... 81
Socioeconomic Status ................................................................................................................. 82
Ethnicity and Cultural Background ......................................................................................... 84
Sociodemographic Variables and Computerised Treatments ..................................... 85
Treatment Compliance .................................................................................................................... 87
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