Initial Evaluation of a Stepped Care Model for Treating Mild to Moderate Childhood Anxiety in Primary Care: A Randomized Controlled Feasibility Trial

INTRODUCTION Anxiety is the most common reason for contact with the first line mental health (FLMH) in Sweden. Anxiety disorders are associated with negative effects in several life areas such as school functioning, peer relationships, and family life. Anxiety disorders in children also predict a number of adverse future events such as depression, alcohol and drug abuse, suicide-attempts, and financial problems in young adulthood. Increasing access to evidence-based interventions (EBIs) for child and adolescent anxiety is an urgent task. Today, only a few children and adolescents with life-interfering anxiety use mental health services.

CBT is a treatment that usually involves efforts to change behavioral and thinking patterns. Numerous studies have found evidence for the efficacy of CBT in the treatment of child anxiety, but typically, these treatment programs have been developed for use in a psychiatric setting. The FLMH assignment focuses on early interventions (prevention and treatment) delivered to children and adolescents (and their parents) with mild to moderate mental health problems. A challenge for the FLMH services has been to identify EBIs for anxiety that fit the needs of their patients and their organization, as the available EBIs almost exclusively have been evaluated within the psychiatric domain (i.e., specialist care) rather than with primary care in mind. To solve this problem, FLMH services sometimes offer a full-length EBI, although it does not fit well into the primary care setting (typically the 10 session CBT group program Cool Kids). Or, more commonly, they shorten the intervention despite that empirical support is lacking concerning whether this can be done with maintained treatment efficacy.

Just because an intervention is evidence-based, it does not always fit seamlessly into a certain care setting. The context where the intervention was developed and tested often differ in substantive ways from the context where it is applied. For instance, staff training, resources and patient characteristics might be different. These differences between health care contexts means that EBIs often need to be adapted to fit with the new context. In the FLMH guidelines, CBT is the recommended intervention for child and adolescent anxiety. However, these guidelines refer to studies of comprehensive interventions, typically including ten or more sessions, developed for children with manifest clinical disorders. Consequently, providing CBT within the FLMH means a dilemma concerned with the extent to which the intervention needs to adhere to the original version and the extent to which changes in response to resource restraints and possibilities in the local care context can be done with maintained treatment acceptability and efficacy.

Recently, the investigators have used a structured co-creative approach to develop a CBT intervention to the FLMH in preparation for the current project. The investigators have conducted workshops with experts on CBT for childhood anxiety and with clinicians and heads of three FLMH units. The investigators have also interviewed parents with experience of participating (together with their child) in CBT for childhood anxiety. Based on this information the investigators have developed a treatment called "Step by Step", a stepped care approach to treat anxiety within primary care. During the past months, the investigators have also preliminary tested the acceptability, appropriateness, and feasibility of the Step-by-Step at one FLMH-unit, including 4 participants. Individual qualitative interviews were conducted with therapists, participating children and caregivers after completing the intervention. Interview data was analyzed using thematic analysis.

OBJECTIVES The overarching aim with this research project is to increase the availability to evidence-based psychological treatments for children with anxiety treated within primary care.