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Williams syndrome (WS) is a rare genetic condition associated with high sociability, intellectual disability, and social cognitive challenges. Attention to others' eyes is crucial for social understanding. Orienting to, and from other's eyes was studied in WS (n = 37, mean age = 23, age range 9-53). The WS group was compared to a typically developing comparison participants (n = 167) in stratified age groups from infancy to adulthood. Typically developing children and adults were quicker and more likely to orient to eyes than the mouth. This bias was absent in WS. The WS group had reduced peak saccadic velocities, indicating hypo-arousal. The current study indicates reduced orienting to others' eyes in WS, which may affect social interaction skills.

The Alabama parenting questionnaire (APQ) is a commonly used instrument for assessing parenting practices and evaluating treatment outcomes of parent‐training interventions targeting child conduct problems. In the present study we translated and developed a Swedish version of the APQ parent version and tested it on a community sample of 799 parents of children between 6 and 15 years with diverse socioeconomic backgrounds. Data were collected through an online survey distributed through school newsletters and social media. Exploratory factor analysis (EFA) suggested a five‐factor model with 23 items. Four of these factors correspond to the subscales suggested in the original version of the APQ: inconsistent discipline, poor monitoring, involvement, and positive parenting. The fifth subscale from the original APQ, corporal punishment, did not show up as a factor in our data sample. Instead, a new factor, which we refer to as contingency management, was revealed. A confirmatory factor analysis further suggested some misalignment between the original APQ subscale structure and our sample, which we interpret as a signal that the instrument may need refinement to better reflect contemporary parenting methods in diverse cultural contexts. Despite this limitation, and with the exclusion of the corporal punishment subscale, which should be employed judiciously, our results suggest that the Swedish version of the APQ can be a useful instrument in measuring parenting practices in Sweden. We present norm data stratified by child age, which practitioners and researchers can use as a reference for assessment of parenting practices in the Swedish population. [ABSTRACT FROM AUTHOR]

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.

Introduction Methods Results Conclusion Transgender and gender‐diverse (TGD) youth experience more stressors and are therefore at a higher risk of health problems compared with their cisgender peers. The aim of this study was to investigate the prevalence of TGD youth in a general population sample and to explore a wide variety of health‐related factors. We investigate differences in stressors and health outcomes between TGD youth and cisgender girls and boys and the influence of stressors and demographic factors on health outcome in the whole group.Cross‐sectional survey data from a Swedish school‐based study were used (N = 3,067, M = 17.8 years). Those who had reported their gender identity as “other” or other than their assigned gender (N = 41) were compared with cisgendered girls (n = 1,544) and boys (n = 1,482). Regression models in the whole group explored if demographics and stressors statistically predicted health outcomes.In comparison with cisgender girls and boys, TGD youth (1.3% of the whole sample) reported a higher prevalence of self‐harm and pain problems. Both TGD youth and cisgender girls more frequently reported insomnia, social anxiety, depressive symptoms, pain, and stressors compared with cisgender boys. When only demographic variables were entered, but not when stressors were added to the model, being TGD magnified the odds of depressive symptoms, sub‐diagnostic social anxiety, and pain problems. Stressors magnified the odds of reporting health problems for the whole group.TGD youth generally reported more stressors, which negatively influence health outcomes. Results are important for professionals who meet TGD youth. [ABSTRACT FROM AUTHOR]

Background: Psychological recidivism-reducing interventions with serious, young violent offenders in residential care have unsatisfactory effects. We tested if a complementary individual cognitive behavioral therapy (iCBT) intervention focusing problem-solving, cognitive self-control, and relapse prevention reduces criminal recidivism beyond usual institutional care encompassing interventions such as social skills training and prosocial modeling (treatment-as-usual; TAU). Method: We consecutively approached 115 eligible serious, male violent crime offenders in five residential treatment homes run by the Swedish National Board of Institutional Care. Eighty-one (70%) 16 to 21-year-old youth at medium-high violent recidivism risk were included and randomized to an individualized 15 to 20-session CBT intervention plus TAU (n = 38) or to TAU-only (n = 43), 4–6 months before release to the community. Participants were assessed pre- and post-treatment, at 12 months (self-reported aggressive behavior, reconvictions) and 24 months (reconvictions) after release. Intent-to-treat analyses were applied. Results: The violent reconviction rate was slightly higher for iCBT+TAU vs. TAU-only youth at 12 months (34 vs. 23%, d = 0.30, 95% CI: −0.24 to 0.84) and 24 months following release (50 vs. 40%, d = 0.23, 95% CI: −0.25 to 0.72), but neither of these differences were significant. Cox regression modeling also suggested non-significantly, negligibly to slightly more violent, and any criminal recidivism in iCBT+TAU vs. TAU-only youth during the entire follow-up. Further, we found no significant between-group differences in conduct problems, aggression, and antisocial cognitions, although both iCBT+TAU and TAU-only participants reported small to large within-group reductions across outcome measures at post-treatment. Finally, the 12-month follow-up suggested marginally more DSM-5 Conduct Disorder (CD) symptoms of "aggression to people and animals" in iCBT+TAU vs. TAU-only youth (d = 0.10, 95% CI: −0.40 to 0.60) although this difference was not significant. Conclusion: We found no additive effect of individual CBT beyond group-based TAU in residential psychological treatment for serious, young male violent offenders. Limited sample size and substantial treatment dropout reduced the robustness of intent-to-treat effect estimates. We discuss the possible impact of treatment dose and integrity, participant retention, and TAU quality. [ABSTRACT FROM AUTHOR]

Background: Social anxiety disorder (SAD) has its typical onset in childhood and adolescence. Maladaptive processing of social information may contribute to the etiology and maintenance of SAD. During face perception, individuals execute a succession of visual fixations known as a scanpath which facilitates information processing. Atypically long scanpaths have been reported in adults with SAD, but no data exists from pediatric samples. SAD has also been linked to atypical arousal during face perception. Both metrics were examined in one of the largest eye-tracking studies of pediatric SAD to date. Methods: Participants were children and adolescents with SAD (n = 61) and healthy controls (n = 39) with a mean age of 14 years (range 10–17) who completed an emotion recognition task. The visual scanpath and pupil dilation (an indirect index of arousal) were examined using eye tracking. Results: Scanpaths of youth with SAD were shorter, less distributed, and consisted of a smaller number of fixations than those of healthy controls. These findings were supported by both frequentist and Bayesian statistics. Higher pupil dilation was also observed in the SAD group, but despite a statistically significant group difference, this result was not supported by the Bayesian analysis. Conclusions: The results were contrary to findings from adult studies, but similar to what has been reported in neurodevelopmental conditions associated with social interaction impairments. Restricted scanpaths may disrupt holistic representation of faces known to favor adaptive social understanding. [ABSTRACT FROM AUTHOR]

Introduction: Individuals tend to explore the left side of a face first and for a longer time in comparison to the right side. This left visual field (LVF) bias is suggested to reflect right hemispheric dominance for face processing. Social anxiety disorder (SAD) is associated with maladaptive interpretations of facial expressions, but it is not known whether this is linked to an atypical LVF bias. Previous studies have reported a reduced LVF bias in autism, a condition overlapping with SAD. This pre-registered study examined the LVF bias in adolescents with SAD. Methods: Eye-tracking was used to investigate the ratio of first fixations to the left on upright and inverted face stimuli in 26 adolescents (13-17 years) with SAD and 23 healthy controls primed to look either between the eyes or at the mouth. Results: The SAD group showed a smaller LVF bias and an atypical face inversion effect when primed to look at the eyes. Autistic traits predicted a smaller LVF bias, independently of social anxiety level. Conclusions: Results suggest that SAD is associated with impaired processing of faces at an early stage of visual scanning. The findings contribute to a better understanding of SAD and its overlap with autism. [ABSTRACT FROM AUTHOR]

Social anxiety disorder (SAD) is a psychiatric condition that often onsets in childhood. Cognitive models underline the role of attention in the maintenance of SAD, but studies on youth populations are few, particularly those using eye tracking to measure attention. Cognitive behavioral therapy (CBT) for SAD includes interventions targeting attention, like exposure to eye contact, but the link between CBT and attention bias is largely unexplored. This study investigated attention bias in youth with SAD and the association with outcome from CBT. Latency to attend to pictures of faces with different emotions (vigilance) and latency to disengage from social stimuli (avoidance) was examined in N = 25 adolescents (aged 13–17) with SAD in relation to treatment outcome. Vigilance was operationalized as the time it took to relocate the gaze from a central position to a peripherally appearing social stimulus. The latency to disengage from a centrally located social stimulus, when a non-social stimulus appeared in the periphery, was used as a proxy for avoidance. Attention characteristics in the SAD group were compared to non-anxious (NA) controls (N = 22). Visual attention was measured using eye tracking. Participants in both the SAD and NA groups were vigilant towards angry faces, compared to neutral and happy faces. Similarly, both groups disengaged attention faster from angry faces. Adolescents with SAD who disengaged faster from social stimuli had less social anxiety after CBT. The results indicate that anxious youth display a vigilant-avoidant attention pattern to threat. However, partly inconsistent with previous research, the same pattern was observed in the NA group. [ABSTRACT FROM AUTHOR]

Objectives Social anxiety disorder (SAD) is one of the most common psychiatric disorders in youth, with a prevalence of about 3%–4% and increased risk of adverse long-term outcomes, such as depression. Cognitive–behavioural therapy (CBT) is considered the first-line treatment for youth with SAD, but many adolescents remain untreated due to limited accessibility to CBT. The aim of this study was to develop and evaluate the feasibility and preliminary efficacy of a therapist-guided internet-delivered CBT treatment, supplemented with clinic-based group exposure sessions (BIP SOFT). Design A proof-of-concept, open clinical trial with 6-month follow-up. Participants The trial was conducted at a child and adolescent psychiatric research clinic, and participants (n=30) were 13–17 years old (83% girls) with a principal diagnosis of SAD. Intervention 12 weeks of intervention, consisting of nine remote therapist-guided internet-delivered CBT sessions and three group exposure sessions at the clinic for the adolescents and five internet-delivered sessions for the parents. Results Adolescents were generally satisfied with the treatment, and the completion rate of internet modules, as well as attendance at group sessions, was high. Post-treatment assessment showed a significant decrease in clinician-rated, adolescent-rated and parent-rated social anxiety (d=1.17, 0.85 and 0.79, respectively), as well as in general self-rated and parent-rated anxiety and depression (d=0.76 and 0.51), compared with pretreatment levels. Furthermore, 47% of participants no longer met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for SAD at post-treatment. At a 6-month follow-up, symptom reductions were maintained, or further improved, and 57% of participants no longer met criteria for SAD. Conclusion Therapist-guided and parent-guided internet-delivered CBT, supplemented with a limited number of group exposure sessions, is a feasible and promising intervention for adolescents with SAD. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.Method: Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.Results: In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.Conclusion: Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. Clinical trial registration information-Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631. [ABSTRACT FROM AUTHOR]

Objectives: In the International Classification of Diseases, Tenth Edition (ICD-10), hypochondriasis (illness anxiety disorder) and dysmorphophobia (body dysmorphic disorder) share the same diagnostic code (F45.2). However, the Swedish ICD-10 allows for these disorders to be coded separately (F45.2 and F45.2A, respectively), potentially offering unique opportunities for register-based research on these conditions. We assessed the validity and reliability of their ICD-10 codes in the Swedish National Patient Register (NPR)., Design: Retrospective chart review., Methods: Six hundred individuals with a diagnosis of hypochondriasis or dysmorphophobia (300 each) were randomly selected from the NPR. Their medical files were requested from the corresponding clinics, located anywhere in Sweden. Two independent raters assessed each file according to ICD-10 definitions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and Fifth Edition criteria. Raters also completed the Clinical Global Impression-Severity (CGI-S) and the Global Assessment of Functioning (GAF)., Primary Outcome Measure: Per cent between-rater agreement and positive predictive value (PPV). Intraclass correlation coefficients for the CGI-S and the GAF., Results: Eighty-four hypochondriasis and 122 dysmorphophobia files were received and analysed. The inter-rater agreement rate regarding the presence or absence of a diagnosis was 95.2% for hypochondriasis and 92.6% for dysmorphophobia. Sixty-seven hypochondriasis files (79.8%) and 111 dysmorphophobia files (91.0%) were considered 'true positive' cases (PPV=0.80 and PPV=0.91, respectively). CGI-S scores indicated that symptoms were moderately to markedly severe, while GAF scores suggested moderate impairment for hypochondriasis cases and moderate to serious impairment for dysmorphophobia cases. CGI-S and GAF inter-rater agreement were good for hypochondriasis and moderate for dysmorphophobia., Conclusions: The Swedish ICD-10 codes for hypochondriasis and dysmorphophobia are sufficiently valid and reliable for register-based studies. The results of such studies should be interpreted in the context of a possible over-representation of severe and highly impaired cases in the register, particularly for dysmorphophobia., Competing Interests: Competing interests: DM-C receives royalties for contributing articles to UpToDate, Wolters Kluwer Health and Elsevier. LFC receives royalties for contributing articles to UpToDate, Wolters Kluwer Health. The rest of authors declare that they have no competing interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited., Objective: To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT)., Design, Setting, and Participants: This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study., Interventions: ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist., Main Outcomes and Measures: The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs., Results: Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group., Conclusions and Relevance: In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD., Trial Registration: ClinicalTrials.gov Identifier: NCT03247075.

Background: One in twenty adolescents experience excessive worry and evidence-based psychological therapies are not sufficiently widespread to reach most of those affected. In this multiple baseline evaluation, we assess the feasibility and preliminary efficacy of a scalable, online cognitive-behavioral intervention for adolescents with excessive worry (BIP worry)., Methods: Thirteen adolescents (age 13-17) with excessive worry underwent the 10-week online BIP worry intervention. The treatment also included an online intervention for parents. Completion rates, treatment satisfaction, and adverse events were measures of feasibility. Clinical outcomes included worry severity, symptoms of other anxiety and depression, and general functioning. To control for time and spontaneous fluctuations in symptoms, adolescents were randomized to a 2-, 6-, or 10-week baseline phase prior to treatment. A short measure of worry severity was administered weekly during the baseline and treatment phases. Outcomes were assessed before the baseline-phase, at pre-treatment, post-treatment, and at 1- and 3-month follow-ups., Results: Twelve of 13 included adolescents, together with their parents, participated in BIP worry, with a mean completion rate of 9.8 of the 10 treatment modules. Adolescents reported an average of 4.4 exposures per week as homework during treatment. High levels of treatment adherence, credibility, and satisfaction, and no serious adverse events were reported. Therapists averaged 21 min per week communicating with each family. Linear mixed effects models indicated significant improvements in worry, anxiety, and general functioning from pre- to post-treatment, with these gains maintained at 1- and 3-months follow-up. Reductions in worry severity during treatment were significantly larger than during the baseline phase. The results from the multiple baseline evaluation suggested an association between the introduction of the BIP worry intervention and subsequent symptom change for some but not all adolescents., Conclusions: BIP worry is a feasible and potentially effective treatment. As the treatment is scalable and involves limited therapist contact, it represents a low-cost method for treating adolescents with excessive worry and anxiety. Further investigation under randomized controlled trial (RCT) conditions is warranted., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 mHealth. All rights reserved.)

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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Child anxiety disorders are highly prevalent and cause significant impairment. Cognitive behavioral therapy (CBT) is recommended for child anxiety disorders, but access to CBT is limited, particularly in rural areas. Internet-delivered CBT (ICBT) can help increase the availability of evidence-based interventions and evidence is beginning to accumulate to indicate that ICBT is efficacious for children with anxiety disorders. However, whether the results of controlled trials are transferrable to real-world clinical settings is unclear. The objective of this study was to evaluate whether therapist-guided ICBT is feasible and potentially effective when implemented in an outpatient clinic in rural Sweden. Children ( N  = 19) aged 8-12 with anxiety disorders underwent a 12-week ICBT program called BiP Anxiety. Feasibility measures included treatment satisfaction, compliance and feedback from clinicians. Clinical outcome measures were clinician-, parent- and child ratings of anxiety symptoms and functional impairment. Overall, participants and clinicians were satisfied with the treatment content and format. There were statistically significant changes from pre- to post-treatment on the primary outcome measure ( t  = - 4.371, p  < 0.001), as well as on all secondary outcome measures. Therapeutic gains were maintained for up to three months from the post-treatment assessment. At follow-up, 68% were no longer in need of treatment and could be discharged from the clinic. The study suggests the feasibility of implementing ICBT in regular health care. Implementation of ICBT could dramatically increase access to evidence based treatment for children with anxiety disorders who live far away from specialist clinics.

Background: Pain-related functional gastrointestinal disorders (P-FGIDs; eg, irritable bowel syndrome) are highly prevalent in children and associated with low quality of life, anxiety, and school absence. Treatment options are scarce, and there is a need for effective and accessible treatments. Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure exercises is effective for adult and adolescent irritable bowel syndrome, but it has not been evaluated for younger children., Objective: The objective of this study was to assess acceptability, feasibility, and potential clinical efficacy of Internet-CBT for children with P-FGIDs., Methods: This was a feasibility study with a within-group design. We included 31 children aged 8-12 years and diagnosed with P-FGID, according to the ROME III criteria. Mean duration of abdominal symptoms at baseline was 3.8 years (standard deviation [SD] 2.6). The treatment was therapist-guided and consisted of 10 weekly modules of exposure-based Internet-CBT. The children were instructed to provoke abdominal symptoms in a graded manner and to engage in previously avoided activities. The parents were taught to decrease their attention to their children's pain behaviors and to reinforce and support their work with the exposures. Assessments included treatment satisfaction, subjective treatment effect, gastrointestinal symptoms, quality of life, pain intensity, anxiety, depression, and school absence. Data were collected at pretreatment, posttreatment, and 6-month follow-up. Means, standard errors (SEs), and Cohen d effect sizes were estimated based on multi-level linear mixed models., Results: Most children 25/31 (81%) completed 9 or 10 of the 10 treatment modules. Almost all children, 28/31 (90%), reported that the treatment had helped them to deal more effectively with their symptoms, and 27/31 (87%) children declared that their symptoms had improved during the treatment. Assessments from the parents were in accordance with the children's reports. No child or parent reported that the symptoms had worsened. We observed a large within-group effect size on the primary outcome measure, child-rated gastrointestinal symptoms from pretreatment to posttreatment (Cohen d=1.14, P<.001, 95% CI 0.69-1.61), and this effect size was maintained at 6-month follow-up (Cohen d=1.40, P<.001, 95% CI 1.04-1.81). We also observed significant improvements from pretreatment to posttreatment on a wide range of child- and parent-rated measures including quality of life, pain intensity, anxiety, depression, and school absence. All results remained stable or were further improved at 6-month follow-up., Conclusions: This study shows that children with longstanding P-FGIDs, and their parents, perceive exposure-based Internet-CBT as a helpful and feasible treatment. The included children improved significantly despite a long duration of abdominal symptoms before the intervention. The treatment shows potential to be highly effective for P-FGIDs. The results need to be confirmed in a randomized controlled trial (RCT)., (©Maria Lalouni, Brjánn Ljótsson, Marianne Bonnert, Erik Hedman-Lagerlöf, Jens Högström, Eva Serlachius, Ola Olén. Originally published in JMIR Mental Health (http://mental.jmir.org), 10.08.2017.)