Long-term outcomes of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders: towards a stepped care model of health care delivery.

Internet-delivered cognitive behaviour therapy (ICBT) is emerging as a powerful tool to fill the gap between demand and availability of evidence-based treatment for paediatric anxiety disorders. However, it is still unclear how to best implement it in routine clinical care. 123 children (8-12 years) with anxiety disorders underwent a 12-week ICBT programme with limited therapist support. Participants were assessed 3- and 12-month post-ICBT (3MFU and 12MFU, respectively). Non-remitters who still fulfilled diagnostic criteria for their principal anxiety disorder at 3MFU were offered additional manualised "face-to-face" (F2F) CBT. The aim of the study was to emulate a stepped-care model of health care delivery, where the long-term treatment gains of ICBT as well as the potential benefit of proving addition treatment to non-remitters of ICBT were evaluated. Remitters of ICBT (n = 73) continued to improve throughout the study period (pre-ICBT to 12MFU; Cohen's d = 2.42). At 12MFU, 89% (n = 65) were free from their principal anxiety disorder. Of all the participants classed as non-remitters at 3MFU (n = 37), 48.6% (n = 18) accepted the offer to receive additional F2F CBT. These participants also improved with a large effect from pre-ICBT to 12MFU (Cohen's d = 2.27), with the largest effect occurring during F2F CBT. At 12MFU, 83% (n = 15) were free from their principal anxiety disorders. The majority of non-remitters declining additional F2F CBT (63.2%; n = 12) did so due to already receiving treatment at their local CAMHS, prior to 3MFU. The effects of ICBT for anxiety disorders are durable at least up to 1 year after the end of treatment. Patients who fail to fully benefit from ICBT improved further with additional F2F sessions at our clinic, suggesting that it may be feasible to implement ICBT within a stepped-care model of health care delivery.

The Work and Social Adjustment Scale, Youth and Parent Versions: Psychometric Evaluation of a Brief Measure of Functional Impairment in Young People.

The Work and Social Adjustment Scale (WSAS) is a brief global measure of functional impairment that is widely used in adult health. We have adapted the WSAS for its use in youth, the WSAS-Youth version (WSAS-Y) and WSAS-Parent version (WSAS-P). This study evaluated the psychometric properties of the scale. The internal consistency, factor structure, convergent and divergent validity, test-retest reliability and sensitivity to change of the WSAS-Y/P were studied in 525 children and adolescents with obsessive-compulsive disorder and related disorders receiving treatment. The internal consistency of the WSAS-Y/P was excellent across diagnostic groups and time-points. Exploratory factor analysis extracted a single-factor of functional impairment, explaining in excess of 85% of the variance. The test-retest reliability was adequate. The WSAS-Y/P correlated more strongly with other measures of functional impairment than with measures of symptom severity, indicating good convergent/divergent validity. Finally, the WSAS-Y/P was highly sensitive to change after treatment.

The Internet Intervention Patient Adherence Scale for Guided Internet-Delivered Behavioral Interventions: Development and Psychometric Evaluation.

BACKGROUND: Patient adherence is defined as the extent to which a patient complies with medical or health advice. At present, there is a lack of reliable and valid measures specifically designed to measure adherence to internet-delivered behavioral interventions. OBJECTIVE: The objective of this study was to develop and psychometrically evaluate a novel measure of adherence to guided internet-delivered behavioral interventions. METHODS: In collaboration with experienced clinicians and researchers in the field, a 5-item, clinician-rated internet intervention Patient Adherence Scale (iiPAS) was developed. The initial scale was tested in a sample of children and adolescents (N=50) participating in internet-delivered cognitive behavioral therapy (ICBT) studies. A revised version of the iiPAS was then administered to a larger sample of children and adolescents (N=148) with various behavioral problems participating in ICBT trials. The scale was evaluated according to a classical test theory framework. RESULTS: The iiPAS demonstrated excellent internal consistency. Factor analyses revealed one underlying factor, explaining about 80% of the variance, suggesting that the scale captures a homogeneous adherence construct. The iiPAS was strongly associated with objective measures of patient activity in ICBT (number of logins, number of written characters, and completed modules). Furthermore, mid- and posttreatment ratings of the iiPAS were significantly correlated with treatment outcomes. By contrast, objective measures of patient activity in the Web-based platform did not correlate with treatment outcomes. CONCLUSIONS: The iiPAS could be a useful tool to measure adherence in a broad range of internet-delivered behavioral interventions.

Sexual health among the oldest old: a population-based study among people aged 85 years and older in Stockholm, Sweden.

Background: Sexual health is an important contributor to the well-being and life satisfaction of people aged ≥85 years, known as the oldest old. However, little is known about sexual health in this population. Aim: To examine aspects of sexual health among the oldest old and explore its associations with sociodemographic, health-related, and lifestyle factors. Methods: We conducted a population-based cross-sectional study including 183 individuals aged ≥85 years who were residents in Stockholm County, Sweden. Responders (response rate, 63%) were interviewed on a range of health, sociodemographic, and lifestyle parameters, including aspects of sexual health. Participants' responses to the sexual health items were reported as proportions with 95% CIs. Associations were examined with multivariable logistic regression. Outcomes: We examined sexual activity, sexual satisfaction, problems related to sexual health, and inquiries on sexual health by a health care provider. Results: Twelve percent of participants (95% CI, 8%-17.6%) were sexually active, and 63.9% (95% CI, 56.5%-70.9%) were satisfied with their sexual lives during the past year. A third (35%; 95% CI, 28.4%-42.2%) reported at least a problem related to sexual health. Only 2.2% (95% CI, 0.6%-5.5%) were asked about sexual health by a health care provider, while 8.2% (95% CI, 4.7%-13.2%) identified a need for such an assessment. Yet, 85.2% (95% CI, 79.3%-90.0%) indicated no need for their sexual health to be evaluated by a health care provider. Being partnered was positively associated with sexual activity (adjusted odds ratio, 9.13; 95% CI, 2.53-32.90), whereas having strong social support was positively associated with being satisfied with one's sexual life (adjusted odds ratio, 2.96; 95% CI, 1.53-5.74). Clinical Implications: Health care providers should be proactive in assessing the sexual health of the oldest individuals. Strengths and Limitations: A representative sample of an underresearched population was used in this study. However, the generalizability of our findings may be restricted due to the small sample. To maintain statistical power from a relatively small sample, we might have lost explanatory power. Given the observational cross-sectional nature of the data, we cannot draw causal inferences based on the observed associations. Conclusions: A 10th of participants were sexually active, and the majority were satisfied with their sexual lives. Although many participants reported problems related to sexual health, few expressed the need to discuss sexual health with health care providers. Future studies should explore potential barriers to addressing sexual health and unmet health care needs among the oldest old.

Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial.

BACKGROUND: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders. METHODS: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257. FINDINGS: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported. INTERPRETATION: ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care. FUNDING: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.

Navigating the development and dissemination of internet cognitive behavioral therapy (iCBT) for anxiety disorders in children and young people: A consensus statement with recommendations from the #iCBTLorentz Workshop Group.

Initial internet-based cognitive behavioral therapy (iCBT) programs for anxiety disorders in children and young people (CYP) have been developed and evaluated, however these have not yet been widely adopted in routine practice. The lack of guidance and formalized approaches to the development and dissemination of iCBT has arguably contributed to the difficulty in developing iCBT that is scalable and sustainable beyond academic evaluation and that can ultimately be adopted by healthcare providers. This paper presents a consensus statement and recommendations from a workshop of international experts in CYP anxiety and iCBT (#iCBTLorentz Workshop Group) on the development, evaluation, engagement and dissemination of iCBT for anxiety in CYP.

Autistic Traits and Symptoms of Social Anxiety are Differentially Related to Attention to Others' Eyes in Social Anxiety Disorder.

Autism spectrum disorder (ASD) and social anxiety disorder (SAD) have partly overlapping symptoms. Gaze avoidance has been linked to both SAD and ASD, but little is known about differences in social attention between the two conditions. We studied eye movements in a group of treatment-seeking adolescents with SAD (N = 25), assessing SAD and ASD dimensionally. The results indicated a double dissociation between two measures of social attention and the two symptom dimensions. Controlling for social anxiety, elevated autistic traits were associated with delayed orienting to eyes presented among distractors. In contrast, elevated social anxiety levels were associated with faster orienting away from the eyes, when controlling for autistic traits. This distinction deepens our understanding of ASD and SAD.