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The Child Internet Project (BiP) – increasing access to evidence-based treatment for children and adolescents via therapist guided internet-delivered cognitive behavior therapy

Eva Serlachius, Sarah Vigerland, Tove Wahlund, Marianne Bonnert, Cathy Creswell Speaker

Despite the fact that cognitive behavior therapy (CBT) is effective for a range of child- and adolescent conditions, and is considered a prioritized psychological treatment option in many national guidelines, few children and adolescents get access to CBT. The treatment gap between the demands for evidence-based psychological treatment in contrast to CBT-trained therapists is a well-known problem. Internet-delivered cognitive behavior therapy (ICBT) is a novel, efficient and cost effective treatment alternative for children and adolescents with psychiatric conditions (such as anxiety disorders) and somatic conditions (such as IBS), which could increase availability to evidence-based treatments. Sarah Vigerland, PhD, will present the background, results and future direction of the Child Internet Project (BiP). BiP has evaluated ICBT for children and adolescents for a range of psychiatric and somatic conditions. Since the start in 2010, BiP has treated over 900 children and adolescents through clinical trials including anxiety disorders, obsessive-compulsive disorders, functional gastrointestinal disorders (e.g., IBS), non-suicidal self-injury and tics. Tove Wahlund, MSc, will present the results from a recently completed clinical trial for adolescents with excessive worry. Marianne Bonnert, PhD, will present the results from a newly conducted clinical trial where ICBT for functional gastrointestinal disorders is implemented in regular care. Maral Jolstedt, MSc, will present secondary outcomes, including predictors, moderators and long-term follow-up from a large stepped care randomized controlled trial for childhood anxiety disorders. The symposium will end with the discussant, Professor Cathy Creswell, giving her thoughts on childhood anxiety disorders, ICBT and implementation in regular care.

Chair: Eva Serlachius, PhD, MD 1* 2*;
Presenters:  Sarah Vigerland, PhD 1* 2*, Tove Wahlund, MSc 1* 2*, Marianne Bonnert, PhD 1* 2*, Maral Jolstedt, MSc 1* 2*;
Discussant: Professor Cathy Creswell 3*

1. Department of Clinical Neuroscience, Karolinska Institutet, Sweden;
2. Stockholm Health Care Services, Stockholm County Council, Sweden;
3. School of Psychology & Clinical Language Sciences, University of Reading, UK (C Creswell) 

1.The Child Internet Project (BiP) – an overview

Sarah Vigerland1,2, Jens Högström1,2, Fabian Lenhard1,2, Kristina Aspvall1,2, Maral Jolstedt1,2, Martina Nordh1,2, Tove Wahlund1,2, Marianne Bonnert1,2, Maria Lalouni1,2, David Mataix-Cols1,2,Clara Hellner1,2, Brjánn Ljótsson1, Eva Serlachius1,2

1Karolinska Institutet, Sweden, 2StockholmHealth Care Services, Stockholm County Council, Sweden

Introduction: The Child internet project (BIP) was formed in 2010 with the objective to increase the availability of evidence-based treatment for children and adolescents with anxiety disorders. At that time, access to such treatments within the Child and Adolescents Mental Health Services (CAMHS) in Stockholm was limited and unevenly distributed between clinics. With the Internet psychiatry unit for adults in Stockholm as a model, BIP started the development of a web platform that could deliver internet-based treatments for anxious youth. 

Method: Between 2010 and 2018, BIP has grown into a program comprised of several research groups and has developed internet-delivered cognitive-behavioral therapies (ICBT) for children and adolescents with anxiety disorders, obsessive compulsive disorder, irritable bowel syndrome, Tourette’s syndrome as well as specific treatments for social anxiety and generalized anxiety disorder. So far, several pilot trials and six RCTs have been completed, five trials are ongoing and an additional studies are being planned. More than 1000 participants have been treated with ICBT in these trials and the number of researchers involved in the BIP-program has grown substantially.

Results: ICBT for youth seems to reduce symptoms and increase functioning in the short- as well as long-term (<12 months="" after="" treatment="" furthermore="" icbt="" seems="" to="" be="" a="" feasible="" and="" acceptable="" even="" though="" therapists="" spend="" on="" average="" 20-30="" minutes="" each="" family="" patient="" parents="" per="" week="" on-going="" trials="" include="" non-inferiority="" trial="" where="" is="" compared="" regular="" face-to-face="" cbt="" as="" well="" implementation="" of="" in="" care="" rural="" sweden="" p="">

Conclusions: BIP has developed and evaluated ICBT treatments for a wide array of disorders. The efficacy of these treatments in a research setting has been confirmed and the next line of studies is moving toward investigating the effectiveness in real-world settings. Plans for and challenges with dissemination will be discussed.

2. Internet-delivered psychological intervention for adolescents with GAD – a multiple baseline evaluation

Tove Wahlund1,2, Maral Jolstedt1,2, Erik Andersson1, Sarah Vigerland1,2, Sean Perrin3,

Eva Serlachius1,2

1Karolinska Institutet, Sweden, 2StockholmHealth Care Services, Stockholm County Council, Sweden, 3Lund University, Sweden.

Introduction: Generalized Anxiety Disorder (GAD) is an impairing anxiety disorder, increasing in prevalence during adolescence and related to impairment and comorbidity later in life. Cognitive Behavioral Therapy (CBT) has been found to be helpful for youth with anxiety disorders. However, many patients who receive CBT do not respond to treatment, the effect of standard CBT on GAD specifically is not clear, and the availability of treatment is limited. Intolerance of uncertainty (i.e. a fear of the unknown) is related to worry among adolescents, and treatment targeting this factor has shown promising results in traditional in-person format. The objective of this study was to evaluate the feasibility and preliminary efficacy of an internet-delivered, intolerance of uncertainty-focused treatment for adolescents with GAD.

Method: Participants were adolescents (N=13), aged 13-17 years, with a principal diagnosis of GAD. The study was conducted as a multiple-baseline evaluation and participants were randomized to different baseline-periods prior to the 10-week treatment period. During the baseline and treatment periods, adolescent rated their level of worry weekly. Follow-up assessments were conducted one and three months after treatment.

Treatment was delivered via a secure internet platform and was exposure-focused, based on the rationale that exposure to thoughts and situations involving uncertainty would increase the tolerance for uncertainty and thus decrease worrying. Treatment consisted of two parallel parts; one for adolescents and one for parents. Both parts comprised 10 modules and included therapist support, and both adolescents and parents were encouraged to complete one module each week. Treatment content consisted of texts, illustrations, written exercises, and animations informing the adolescents and parents about how to reduce excessive worry and helping them plan exercises for each week.

Results: After ten weeks of treatment, 50 % of participants no longer fulfilled criteria for GAD and the mean PSWQ-C score had decreased from 33.5 points (sd = 4.06) to 25 points (s = 8.06), p =.007. Visual inspection of self-rated worry indicated that change occurred only after the introduction of the treatment. Both adolescents and parents completed on average 9.75 modules. There was one drop-out at the first week of treatment (due to severe depressive symptoms), all other participants completed treatment as well as post- and follow-up assessments. Results at 1-month and 3-months will be presented.

Discussion:Improvements on self-rated worry, high adherence to treatment and low drop out rate indicate thatthe internet-version of a psychological intervention focused on intolerance of uncertainty for adolescents with GAD was well accepted by families, appears to be feasible and may be effective in reducing worry.

3. Internet-delivered exposure therapy for pediatric functional abdominal pain disorders:

An open pilot implementation study

Marianne Bonnert 1,2, Ola Olén 1, Maria Lalouni 1,2, Erik Hedman-Lagerlöf1, Hanna Sahlin1,2, Josefin Särnholm1, Eva Serlachius1,2 & Brjánn Ljótsson PhD1

1Karolinska Institutet, Sweden, 2Stockholm Health Care Services, Stockholm County Council, Sweden

Background: Functional abdominal pain disorders (FAPD) are highly prevalent (13%) in children and adolescents worldwide. FAPD is associated with anxiety and depression, school absenteeism, high health care consumption and a low quality of life. The evidence for medical or diet treatment is weak, but cognitive behavioral therapy (CBT) has shown promising effects. However, there are few available therapists trained in CBT for pediatric FAPD. To reduce the treatment gap internet-delivered exposure based CBT (Internet-CBT) was developed and evaluated for children and adolescents with FAPD. Internet-CBT has shown significant and stable long-term effects on a broad range of outcomes. However, it is still unclear how to best transfer Internet-CBT for children and adolescents with FAPD into regular care. The objective of this study was to evaluate the feasibility and potential effects of Internet-CBT when conducted in regular care and preliminary compare the results from a national unit specialized on the Internet-CBT for FAPD with three regional pediatric clinics.

Method: This was an open pilot with a pretest-posttest design. Sixty-eight children and adolescents with FAPD aged 8-17 years were included, with 41 participants included at the national specialized unit and 27 participants included at the regional clinics. The Internet-CBT consisted of 10 weekly modules, which focused mainly on exposure to abdominal symptoms and reduction of avoidance behaviors. Feasibility criteria included adherence, treatment credibility, treatment satisfaction and potential efficacy. The primary outcome for potential efficacy was global gastrointestinal symptoms. Secondary outcomes included quality of life, school absenteeism, avoidance behavior and fear of symptoms. Assessment points were at pre-treatment and at post-treatment.

Results: Feasibility and potential efficacy will be presented for the whole sample as well as a preliminary evaluation of feasibility and efficacy when comparing a national specialized Internet-CBT unit with regional pediatric clinics.

Conclusions: This study contributes with increased knowledge of implementation of Internet-CBT by investigating whether feasibility and efficacy are maintained when the treatment is performed by psychologists in regular care at a regional pediatric clinic.  Implications will be discussed at the conference.

4. Long-term effects of internet-delivered cognitive behavior therapy within a stepped care model

Maral Jolstedt1,2, Tove Wahlund1,2, Martina Nordh1,2, Brjánn Ljótsson1, Jens Högström1,2, David Mataix-Cols1,2, Eva Serlachius1,2, Sarah Vigerland1,2

 1Karolinska Institutet, Sweden, 2StockholmHealth Care Services, Stockholm County Council, Sweden

Introduction: Pediatric anxiety disorders are common and can cause significant impairment later in life if left untreated. Cognitive behavior therapy (CBT) has been found to be an effective treatment for children and adolescents with a range of disorders; however, many children do not get access to CBT. Internet-delivered CBT (ICBT) has the potential to increase availability in a cost-effective manner. However, even though ICBT has been found to be effective for the majority of participants in several trials, little is known about how it should be implemented within regular health care. The possibility of a stepped-care approach has been suggested, but never tested. The objective of this study was therefore to evaluate the effects of ICBT within a stepped-care model, where non-responders were offered additional face-to-face CBT, as well as the long-term (12 month) outcomes of ICBT (with or without additional face-to-face CBT)

Method: Participants were children (N=131), aged 8-12 years, with a principal anxiety disorder (separation anxiety, generalized anxiety, panic disorder, social anxiety disorder, specific phobia). If still fulfilling their principal anxiety disorder three months after completed ICBT, participants were offered 12 weeks of traditional face-to-face CBT. Participants were assessed three months post ICBT (i.e., pre CBT treatment), at post CBT treatment, and 12 months after completed ICBT regardless of additional CBT or not. Primary outcome measure was clinically assessed symptom severity measured with ADIS-C/P. Secondary outcome measures included self- and parent reported anxiety symptoms, functional impairment and life-quality.

Results: The proportion of participants in need of treatment after completed ICBT and the effects of face-to-face CBT as an additional treatment to non-responders will be presented, as well as the long-term effects of ICBT, with or without additional face-to-face CBT.

Discussion: The effects and feasibility of ICBT in a stepped care model will be discussed. ICBT has the potential to increase availability to evidence-based treatments. However, even though the growing research on pediatric ICBT for anxiety disorders indicate that it is an effective treatment, little is known about how it should be implemented and made available in regular health care. The presented findings from this trial may help understand whether a stepped-care model for the implementation of ICBT is feasible.