NIHR Signal Talking therapy given by parents shows promise for childhood anxiety disorders

Published on 8 August 2017

Brief guided cognitive behavioural therapy (CBT) delivered by parents was as good as a commonly used treatment, delivered by a therapist, in improving anxiety levels in children. Anxiety continued to improve after the end of treatment and by six months about 70% had recovered. The brief CBT was potentially the more cost-effective option.

This NIHR-funded trial compared recovery from a range of common anxiety disorders in children aged five to 12 following these brief psychological treatments. CBT was delivered by parents instructed and supported in its use by a mental health worker. It was compared with a treatment commonly used in the NHS, a solution-focused brief therapy delivered directly by a trained therapist.

Brief interventions such as these have the potential to improve outcomes at a reasonable cost for children with this common debilitating condition.

Talking therapy given by parents shows promise for childhood anxiety disorders

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Why was this study needed?

Anxiety disorders are among the most common mental health conditions during childhood, affecting 2 to 5% of children younger than twelve. The symptoms can persist through to adulthood and are associated with dropping out of education and depression later in life.

Even though less than one in three children with anxiety disorders access professional help, demand is outweighing NHS resources. Traditional CBT is effective in about 60% but typically requires 14 to 16 sessions.

Solution-focused brief therapy is now becoming more widespread. This targets the child’s strengths to build solutions, reserving CBT for those who continue to be symptomatic.

A brief version of parent-delivered CBT has been suggested as an alternative and this study looked at whether it was superior to solution-focused brief therapy in children with anxiety.

What did this study do?

This randomised controlled trial compared both therapies for treatment of anxiety disorders in 136 children aged five to 12 in Oxfordshire. Children had a primary diagnosis of separation anxiety, social anxiety, generalised anxiety or a specific phobia.

Brief guided parent-delivered CBT focused on teaching parents about childhood anxiety and how to deliver it. The parents had four 45 minute face-to-face sessions and four 15 minute telephone sessions with a mental health worker plus homework tasks over eight weeks. The solution-focused brief therapy was delivered directly by the therapist. The parent joined the child for the first and last hourly sessions and the child attended four 45 minute face-to-face sessions. Both treatment groups received approximately five hours of therapy.

The main limitations were the inclusion of children with different types and severity of anxiety disorders made it hard to see if one treatment had particular benefits for one group. The recruitment from an area where 40% of the parents had received higher education and over 90% identified as White British made the results harder to apply to other populations.

What did it find?

  • Parent-delivered CBT was not more clinically effective than solution-focused therapy. Recovery from the primary anxiety disorder occurred in 50% of the parent-delivered CBT group immediately after treatment, increasing to 69% by six months. Recovery in the solution-focused brief therapy group was 59% at treatment end and 68% after six months, with no significant difference between the groups (relative risk 1.09, 95% confidence interval [CI] 0.92 to 1.30).
  • A ‘much’ or ‘very much’ improvement on the Clinical Global Impression of Improvement (CGI-I) score, a scale with seven grades of improvement, was found in 59% of children in the parent-delivered CBT group after treatment, increasing to 66% after six months. The results for children in the solution-focused brief therapy group were 69% initially and 72% after six months. There was no significant difference between groups at either time point.
  • QALYs gained over the trial period did not differ significantly between groups in the base-case analysis (mean difference 0·006, 95% CI –0·009 to 0·02).The mean societal short-term cost per child was £1,494 in the parent-delivered CBT group compared with £1,942 in the solution-focused brief therapy group. This difference was not statistically significant (mean difference -£448, 95% CI -£934 to £37). Cost effectiveness estimates remained uncertain.
  • The main drivers of the slightly lower cost per patient in the parent-delivered CBT group were costs of treatment due to less travelling because of telephone reviews and time off school, work or leisure time.
  • Uptake may be an issue as more parents (13/68) did not start or complete therapy than children (3/68).

What does current guidance say on this issue?

The NICE 2013 guideline on recognition, assessment and treatment of social anxiety disorder recommends offering children individual or group CBT focused on social anxiety. It also recommends considering involving parents or carers to ensure effective delivery of the intervention, particularly in young children.

There is no specific UK guidance for children with the other types of anxiety disorders that were included in this study: separation anxiety, social anxiety, generalised anxiety or specific phobias.

What are the implications?

Solution-focused brief therapy is the commonest initial treatment for childhood anxiety disorders in the study centres recruited here as limited resources restrict the use of CBT to more severe cases. These findings suggest that parent-delivered CBT may be a promising alternative option which is potentially cheaper.

It could be relatively easy to deliver within the NHS. The therapists were primary mental health workers with a variety of backgrounds who were given two days of training, and the treatment is standardised with use of a manual and workbooks. This was a relatively small study conducted only in Oxfordshire so further validation will be required. Also suitability and acceptability in the specific sub-groups of anxiety disorders should be ascertained.

Citation and Funding

Creswell C, Violato M, Fairbanks H, et al. Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry. 2017;4(7):529-39.

This project was funded by the National Institute for Health Research [Research for Patient Benefit] (reference number PB-PG-0110-21190).

Bibliography

NHS Choices. Anxiety disorders in children. London: Department of Health; 2016.

NHS Choices. Cognitive Behavioural Therapy. London: Department of Health; 2016.

NICE. Anxiety disorders. QS53. London: National Institute for Health and Clinical Excellence; 2014.

NICE. Generalised anxiety disorder and panic disorder in adults: management. CG113. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Social anxiety disorder: recognition, assessment and treatment. CG159. London: National Institute for Health and Clinical Excellence; 2013.

Khan L, Parsonage M, Stubbs J. Investing in children’s mental health: A review of evidence on the costs and benefits of increased service provision. London: Centre for Mental Health; 2015.

Why was this study needed?

Anxiety disorders are among the most common mental health conditions during childhood, affecting 2 to 5% of children younger than twelve. The symptoms can persist through to adulthood and are associated with dropping out of education and depression later in life.

Even though less than one in three children with anxiety disorders access professional help, demand is outweighing NHS resources. Traditional CBT is effective in about 60% but typically requires 14 to 16 sessions.

Solution-focused brief therapy is now becoming more widespread. This targets the child’s strengths to build solutions, reserving CBT for those who continue to be symptomatic.

A brief version of parent-delivered CBT has been suggested as an alternative and this study looked at whether it was superior to solution-focused brief therapy in children with anxiety.

What did this study do?

This randomised controlled trial compared both therapies for treatment of anxiety disorders in 136 children aged five to 12 in Oxfordshire. Children had a primary diagnosis of separation anxiety, social anxiety, generalised anxiety or a specific phobia.

Brief guided parent-delivered CBT focused on teaching parents about childhood anxiety and how to deliver it. The parents had four 45 minute face-to-face sessions and four 15 minute telephone sessions with a mental health worker plus homework tasks over eight weeks. The solution-focused brief therapy was delivered directly by the therapist. The parent joined the child for the first and last hourly sessions and the child attended four 45 minute face-to-face sessions. Both treatment groups received approximately five hours of therapy.

The main limitations were the inclusion of children with different types and severity of anxiety disorders made it hard to see if one treatment had particular benefits for one group. The recruitment from an area where 40% of the parents had received higher education and over 90% identified as White British made the results harder to apply to other populations.

What did it find?

  • Parent-delivered CBT was not more clinically effective than solution-focused therapy. Recovery from the primary anxiety disorder occurred in 50% of the parent-delivered CBT group immediately after treatment, increasing to 69% by six months. Recovery in the solution-focused brief therapy group was 59% at treatment end and 68% after six months, with no significant difference between the groups (relative risk 1.09, 95% confidence interval [CI] 0.92 to 1.30).
  • A ‘much’ or ‘very much’ improvement on the Clinical Global Impression of Improvement (CGI-I) score, a scale with seven grades of improvement, was found in 59% of children in the parent-delivered CBT group after treatment, increasing to 66% after six months. The results for children in the solution-focused brief therapy group were 69% initially and 72% after six months. There was no significant difference between groups at either time point.
  • QALYs gained over the trial period did not differ significantly between groups in the base-case analysis (mean difference 0·006, 95% CI –0·009 to 0·02).The mean societal short-term cost per child was £1,494 in the parent-delivered CBT group compared with £1,942 in the solution-focused brief therapy group. This difference was not statistically significant (mean difference -£448, 95% CI -£934 to £37). Cost effectiveness estimates remained uncertain.
  • The main drivers of the slightly lower cost per patient in the parent-delivered CBT group were costs of treatment due to less travelling because of telephone reviews and time off school, work or leisure time.
  • Uptake may be an issue as more parents (13/68) did not start or complete therapy than children (3/68).

What does current guidance say on this issue?

The NICE 2013 guideline on recognition, assessment and treatment of social anxiety disorder recommends offering children individual or group CBT focused on social anxiety. It also recommends considering involving parents or carers to ensure effective delivery of the intervention, particularly in young children.

There is no specific UK guidance for children with the other types of anxiety disorders that were included in this study: separation anxiety, social anxiety, generalised anxiety or specific phobias.

What are the implications?

Solution-focused brief therapy is the commonest initial treatment for childhood anxiety disorders in the study centres recruited here as limited resources restrict the use of CBT to more severe cases. These findings suggest that parent-delivered CBT may be a promising alternative option which is potentially cheaper.

It could be relatively easy to deliver within the NHS. The therapists were primary mental health workers with a variety of backgrounds who were given two days of training, and the treatment is standardised with use of a manual and workbooks. This was a relatively small study conducted only in Oxfordshire so further validation will be required. Also suitability and acceptability in the specific sub-groups of anxiety disorders should be ascertained.

Citation and Funding

Creswell C, Violato M, Fairbanks H, et al. Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry. 2017;4(7):529-39.

This project was funded by the National Institute for Health Research [Research for Patient Benefit] (reference number PB-PG-0110-21190).

Bibliography

NHS Choices. Anxiety disorders in children. London: Department of Health; 2016.

NHS Choices. Cognitive Behavioural Therapy. London: Department of Health; 2016.

NICE. Anxiety disorders. QS53. London: National Institute for Health and Clinical Excellence; 2014.

NICE. Generalised anxiety disorder and panic disorder in adults: management. CG113. London: National Institute for Health and Clinical Excellence; 2011.

NICE. Social anxiety disorder: recognition, assessment and treatment. CG159. London: National Institute for Health and Clinical Excellence; 2013.

Khan L, Parsonage M, Stubbs J. Investing in children’s mental health: A review of evidence on the costs and benefits of increased service provision. London: Centre for Mental Health; 2015.

Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial

Published on 22 May 2017

Creswell, C.,Violato, M.,Fairbanks, H.,White, E.,Parkinson, M.,Abitabile, G.,Leidi, A.,Cooper, P. J.

Lancet Psychiatry , 2017

BACKGROUND: Half of all lifetime anxiety disorders emerge before age 12 years; however, access to evidence-based psychological therapies for affected children is poor. We aimed to compare the clinical outcomes and cost-effectiveness of two brief psychological treatments for children with anxiety referred to routine child mental health settings. We hypothesised that brief guided parent-delivered cognitive behavioural therapy (CBT) would be associated with better clinical outcomes than solution-focused brief therapy and would be cost-effective. METHODS: We did this randomised controlled trial at four National Health Service primary child and mental health services in Oxfordshire, UK. Children aged 5-12 years referred for anxiety difficulties were randomly allocated (1:1), via a secure online minimisation tool, to receive brief guided parent-delivered CBT or solution-focused brief therapy, with minimisation for age, sex, anxiety severity, and level of parental anxiety. The allocation sequence was not accessible to the researcher enrolling participants or to study assessors. Research staff who obtained outcome measurements were masked to group allocation and clinical staff who delivered the intervention did not measure outcomes. The primary outcome was recovery, on the basis of Clinical Global Impressions of Improvement (CGI-I). Parents recorded patient-level resource use. Quality-adjusted life-years (QALYs) for use in cost-utility analysis were derived from the Child Health Utility 9D. Assessments were done at baseline (before randomisation), after treatment (primary endpoint), and 6 months after treatment completion. We did analysis by intention to treat. This trial is registered with the ISCRTN registry, number ISRCTN07627865. FINDINGS: Between March 23, 2012, and March 31, 2014, we randomly assigned 136 patients to receive brief guided parent-delivered CBT (n=68) or solution-focused brief therapy (n=68). At the primary endpoint assessment (June, 2012, to September, 2014), 40 (59%) children in the brief guided parent-delivered CBT group versus 47 (69%) children in the solution-focused brief therapy group had an improvement of much or very much in CGI-I score, with no significant differences between groups in either clinical (CGI-I: relative risk 1.01, 95% CI 0.86-1.19; p=0.95) or economic (QALY: mean difference 0.006, -0.009 to 0.02; p=0.42) outcome measures. However, brief guided parent-delivered CBT was associated with lower costs (mean difference - pound448; 95% CI -934 to 37; p=0.070) and, taking into account sampling uncertainty, was likely to represent a cost-effective use of resources compared with solution-focused brief therapy. No treatment-related or trial-related adverse events were reported in either group. INTERPRETATION: Our findings show no evidence of clinical superiority of brief guided parent-delivered CBT. However, guided parent-delivered CBT is likely to be a cost-effective alternative to solution-focused brief therapy and might be considered as a first-line treatment for children with anxiety problems. FUNDING: National Institute for Health Research.

Expert commentary

Most adults with poor mental health experienced their first difficulties before their mid-teens, so this comparison of parent-delivered CBT with solution-focused brief therapy for children with anxiety disorders is an important addition to the emergent but limited evidence-base for child mental health. The findings suggest that brief intervention via parents was the more cost-effective intervention but provides the first evidence also that solution-focused therapy, the commonly used active comparator is also an effective intervention for this group. Further research should explore factors that make one or other more or less effective for a particular child and their family.

Tamsin Ford, Professor of Child and Adolescent Psychiatry, University of Exeter