Fluent Essays

Attached are the instructions, an example, and the articles. Article Summaries Instructions Critique all three articles separately. In your summary, identify and analyze the basic components of research; purpose, research question, hypothesis, research design, variables of interest (independent and dependent), selection/sampling, instrument(s), data collection, data analysis, research findings, ethical and multicultural considerations, strength and limitations, implications for practice, and implications for future research. See example in attachment. Also the three article links are below and attached: Article 1: Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders https://www.jaacap.org/article/S0890-8567(20)30280-X/fulltext Article 2: Potential mechanisms of change in cognitive behavioral therapy for childhood anxiety: A meta-analysis. Article 3: Guided Internet-based Cognitive Behavioral Therapy for Adolescent Anxiety: Predictors of Treatment Response Bottom of Form You will be writing a summary of a PEER REVIEWED research article. Please read all of these boxes to make sure you are following instructions. You must include a SEPARATE TITLE PAGE that includes your instructor’s name, section, time/day the class meets, your name, student id # APA STYLE TITILE PAGE HERE Gesturing gives children new idea Article Title s about math The paper must be typed, double- spaced, and have 1-inch margins on all sides. It should be a minimum of 300 words. The purpose of this study was to show how gesture can enhance math performance. It was an experimental research study that looked at how gesture effects children’s learning of math, particularly addition. The independent variable was gesture with three different conditions; gesture, no gesture, and partial gesture. The dependent variable of the study was the difference between pre- and post- test scores on a math task. The mediator variable was the speech being used during the lesson. The lesson was where the independent variable changed. Participants were brought in for the study and were first given a demographics worksheet. Once their demographics were determined, they were given a pre-test to be aware of prior knowledge. Once the pre-test was graded, a lesson was given either with gesture that was grouping through two fingers, no gesture or a partial gesture which was just pointing. Once the lesson on the math was given, the post-test was given. The experimenters then determined a difference from pre- to post- tests scores.What the article was about The major conclusion to this study was that the gesturing condition showed higher math scores than the partially correct which was higher than the no gesture condition, showing that the gesturing actually aided in the child remembering the math task by using their body to perform it.What the study found However in this study there was no speech within the lesson. The only speech used was “This side is equal to the other side.” This was the only speech used within the lesson. Since this was the only speech, the lesson was highly dependent on the use of the gestures, which in my opinion could be questionable. The questions arise, should gesture be tested with more verbal instruction. Does the gesture give the same effect? One may also ask, does this relate to older or younger kids who are learning a different type of math? Reference page below Your opinion of the study References You will need a complete reference page for your article. This SHOULD be done in APA Style. You will need a copy of the first page of the PEER REVIEWED article you chose after the reference page. Goldin-Meadow, S., Cook, S. W, Mitchell, Z. A. (2009). Gesturing gives children new ideas about math. Current Directions in Psychological Science, 17(5), 313-317. Print out the first page of the article and put it behind the reference page See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/256773542 Child-Parent Interventions for Childhood Anxiety Disorders: A Systematic Review and Meta-Analysis Article  in  Research on Social Work Practice · September 2013 DOI: 10.1177/1049731513503713 CITATIONS 26 READS 1,089 2 authors: Kristen Esposito Brendel Aurora University 11 PUBLICATIONS   167 CITATIONS    SEE PROFILE Brandy R Maynard Saint Louis University 92 PUBLICATIONS   2,196 CITATIONS    SEE PROFILE All content following this page was uploaded by Brandy R Maynard on 31 May 2014. The user has requested enhancement of the downloaded file. https://www.researchgate.net/publication/256773542_Child-Parent_Interventions_for_Childhood_Anxiety_Disorders_A_Systematic_Review_and_Meta-Analysis?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_2&_esc=publicationCoverPdf https://www.researchgate.net/publication/256773542_Child-Parent_Interventions_for_Childhood_Anxiety_Disorders_A_Systematic_Review_and_Meta-Analysis?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_3&_esc=publicationCoverPdf https://www.researchgate.net/?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_1&_esc=publicationCoverPdf https://www.researchgate.net/profile/Kristen-Esposito-Brendel?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_4&_esc=publicationCoverPdf https://www.researchgate.net/profile/Kristen-Esposito-Brendel?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_5&_esc=publicationCoverPdf https://www.researchgate.net/institution/Aurora_University?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_6&_esc=publicationCoverPdf https://www.researchgate.net/profile/Kristen-Esposito-Brendel?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_7&_esc=publicationCoverPdf https://www.researchgate.net/profile/Brandy-Maynard?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_4&_esc=publicationCoverPdf https://www.researchgate.net/profile/Brandy-Maynard?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_5&_esc=publicationCoverPdf https://www.researchgate.net/institution/Saint_Louis_University?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_6&_esc=publicationCoverPdf https://www.researchgate.net/profile/Brandy-Maynard?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_7&_esc=publicationCoverPdf https://www.researchgate.net/profile/Brandy-Maynard?enrichId=rgreq-e25afa1c346af7b97181a34876e81ad2-XXX&enrichSource=Y292ZXJQYWdlOzI1Njc3MzU0MjtBUzoxMDI5NDU1MTc0NzM3OThAMTQwMTU1NTUzMjQyMg%3D%3D&el=1_x_10&_esc=publicationCoverPdf http://rsw.sagepub.com/ Research on Social Work Practice http://rsw.sagepub.com/content/early/2013/09/19/1049731513503713 The online version of this article can be found at: DOI: 10.1177/1049731513503713 published online 19 September 2013Research on Social Work Practice Kristen Esposito Brendel and Brandy R. Maynard Parent Interventions for Childhood Anxiety Disorders: A Systematic Review and Meta-Analysis−Child Published by: http://www.sagepublications.com can be found at:Research on Social Work PracticeAdditional services and information for http://rsw.sagepub.com/cgi/alertsEmail Alerts: http://rsw.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: What is This? - Sep 19, 2013OnlineFirst Version of Record >> at SAINT LOUIS UNIV on September 20, 2013rsw.sagepub.comDownloaded from http://rsw.sagepub.com/ http://rsw.sagepub.com/content/early/2013/09/19/1049731513503713 http://www.sagepublications.com http://rsw.sagepub.com/cgi/alerts http://rsw.sagepub.com/subscriptions http://www.sagepub.com/journalsReprints.nav http://www.sagepub.com/journalsPermissions.nav http://rsw.sagepub.com/content/early/2013/09/19/1049731513503713.full.pdf http://online.sagepub.com/site/sphelp/vorhelp.xhtml http://rsw.sagepub.com/ Research Article Child–Parent Interventions for Childhood Anxiety Disorders: A Systematic Review and Meta-Analysis Kristen Esposito Brendel 1 and Brandy R. Maynard 2 Abstract Objective: This study compared the effects of direct child–parent interventions to the effects of child-focused interventions on anxiety outcomes for children with anxiety disorders. Method: Systematic review methods and meta-analytic techniques were employed. Eight randomized controlled trials examining effects of family cognitive behavior therapy compared to individual or group child-only therapy met criteria. Results: The overall mean effect of parent–child interventions was 0.26, 95% confidence interval [0.05, 0.47], p < .05, a small but positive and significant effect, favoring child–parent interventions. Results of the heterogeneity analysis were not significant (Q ¼ 8.08, df ¼ 7, p > .05, I2 ¼ 13.41). Discussion: Parent–child interventions appear to be more effective than child-focused individual and group cognitive behavioral therapy in treating childhood anxiety disorders. Implications for practice and research are discussed. Keywords anxiety disorder, systematic review, meta-analysis, family cognitive behavioral therapy Childhood anxiety disorders are the most prevalent of all childhood psychiatric disorders, with lifetime prevalence esti- mates ranging from 2.6% to 32% (American Psychological Association, 2000; Cartwright,-Hatton, McNicol, & Doubleday, 2006; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Merikangas, He, Burstein, Swanson, Avenevoli, Cui, et al., 2010). Childhood anxiety disorders have been linked to signifi- cant negative implications for children across social, academic and family domains and serious mental disorders, such as depression, substance use disorders, and other anxiety disorders in later adolescence and adulthood (Albano, Chorpita, & Bar- low, 2003; Bittner et al., 2007; Langley, Bergman, McCracken, & Piacentini, 2004). In light of the high prevalence and rates of comorbidity with other behavioral and emotional problems, longitudinal and population-based research examining corre- lates, causes, and the developmental course of childhood anxiety disorders has increased, including a focus on family and parental factors that contribute to childhood anxiety disorders. During the past two decades, a growing body of research examining parental factors in relation to childhood anxiety dis- orders suggests that parental anxiety and modeling behaviors contribute to the development and maintenance of childhood anxiety disorders (Choate, Pincus, Eyberg, & Barlow, 2005; Ginsburg & Schlossberg, 2002; Rapee, 1997; Siqueland, Ken- dall, & Steinberg, 1996). Research suggests an intergenerational transmission of anxiety, with both genetic and environmental factors implicated. Children are estimated to be 3 or 5 times more likely to develop an anxiety disorder if one parent has an anxiety disorder and 6 times more likely if both parents have an anxiety disorder (Beidel & Turner, 1997; Last, Hersen, Kazdin, Francis, & Grubb, 1991; Merikangas, Avenevoli, Dier- ker, & Grillon, 1999). Additional parent-related risk factors have been implicated in the cause and maintenance of childhood anxiety disorders including high parental control, insecure attach- ment, and parental modeling of poor coping strategies (Ginsburg & Schlossberg, 2002; Maid, Smokowski, & Bacallao, 2008; Silverman & Dick-Niederhauser, 2004; Wood, McLeod, Sigman, Hwang, & Chu, 2003). Child–Parent Interventions for Childhood Anxiety Disorders In light of the growing research suggesting an influence of parental factors in the development and maintenance of child- hood anxiety disorders, a growing number of child–parent interventions have been developed and purported as efficacious in the treatment of childhood anxiety disorders. Research also supports the integration of parents in child therapy as a means 1 School of Social Work, Aurora University, IL, USA 2 School of Social Work, Saint Louis University, MO, USA Corresponding Author: Kristen Esposito Brendel, School of Social Work, Aurora University, 347 Gladstone, Aurora, IL 60506, USA. Email: [email protected] Research on Social Work Practice 00(0) 1-9 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049731513503713 rsw.sagepub.com at SAINT LOUIS UNIV on September 20, 2013rsw.sagepub.comDownloaded from http://www.sagepub.com/journalsPermissions.nav http://rsw.sagepub.com http://rsw.sagepub.com/ to better generalize skills from the clinician’s office to the home environment and for both the children and the parents to learn and practice better methods to cope with issues of anxiety that may be pervasive within the household (Bodden et al., 2008; Bogels & Siqueland, 2006; Mendlowitz et al., 1999; Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006). Although all child–parent interventions have a common factor, that the child and parent participate in the intervention together, there are variations in the theories and methods used across the array of child–parent interventions currently in prac- tice. Some of the most common child–parent interventions include family cognitive behavioral therapy (FCBT), parent- child interaction therapy (PCIT), child–parent psychotherapy (CPP), and Theraplay. Family Cognitive Behavioral Therapy. FCBT integrates cognitive behavioral therapy in a family setting that includes parents and children; the family is seen as the most favorable setting for effecting change in children’s irrational thoughts. FCBT typi- cally involves a treatment manual that guides the therapeutic process and helps family members recognize essential thoughts that are irrational and reframe them as more rational and pro- ductive types of beliefs (Bogels & Siqueland, 2006; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). FCBT directly focuses on the most common parental factors that have been associated with the development and maintenance of childhood anxiety disorders, including parental control, acceptance, and modeling, as well as other issues identified during the assessment process and throughout treatment. More- over, FCBT encourages parents to facilitate new opportunities with their children to test distorted beliefs when at home and while jointly engaging in community activities (Barrett & Shortt, 2003). Parents also can model their own functional cognition and behaviors to their children during the treatment process and at home. Parent-Child Interaction Therapy. PCIT integrates play therapy with developmental, social learning, and behavioral theories. Although originally developed for preschool-age children experiencing externalizing behavioral problems (Brinkmeyer & Eyberg, 2003; Herschell & McNeil, 2005), researchers have begun to investigate PCIT for other issues, including victims of physical abuse, children in foster care, children with develop- mental delays (Chaffin, Taylor, Wilson, & Igelman, 2007; Herschell & McNeil, 2005), and children with separation anxiety disorder (SAD; Choate et al., 2005; Herschell & McNeil, 2005). Similar to FCBT, the premise of PCIT for children with anxiety disorders is to effect change within the parent–child system. PCIT is typically conducted in two phases, a child-directed phase and then a parent-directed phase. During each phase, par- ents learn how to modify their own actions, hence modifying the reactions of their children. PCIT enhances parent–child relation- ships by fostering healthy attachments, modifying reinforcement contingencies, and reducing anxiety-provoking responses (Cho- ate et al., 2005). Child-Parent Psychotherapy. CPP is a model of family play therapy that involves treatment of the parent–child unit, using play as the primary medium of intervention (Lieberman & Van Horn, 2005). Lieberman and colleagues posit that by using play in con- joined sessions with child and parent, parental understanding of the child’s inner experience increases, as well as trust, recipro- city, and pleasure within the parent–child relationship (Lieber- man & Inman, 2009). CPP involves the parent actively playing with the child in the therapeutic milieu. It is a relationship-based intervention that helps to change mutual reinforcement of negative behaviors and instead enhances emotional attunement (Lieberman & Van Horn, 2005). Because CPP is designed to facilitate positive and healthy associations between parent and child, it is conjectured that it can also be helpful for children with anxiety disorders. Research needs to be conducted on the efficacy of CPP as an intervention specifically for children with anxiety disorders. Theraplay. Theraplay is a systematic procedure invented by Ann M. Jernberg in the 1960s to increase positive interactions between parent and child (Jernberg, 1979). Jernberg modeled Theraplay after Winnicott’s (1958) notion of being a ‘‘good enough mother.’’ Five dimensions present in mother–child interactions are postulated in this model: structuring, challen- ging, engagement, nurturing, and play. Jernberg formulated Theraplay after these dimensions, with the premise that parent–child interactions can be therapeutic for a number of childhood disorders by fostering bonding, attunement, and play- fulness (Jernberg, 1999; Wettig, Franke, & Fjordbark, 2006). As research during the past decade has begun to elucidate the relationship of parental influences and behavior and the causes and maintenance of anxiety disorders in children, prac- titioners have begun to treat childhood anxiety disorder in the context of child–parent interventions. Although child–parent interventions are widely used and supported by practitioners, little is known about the effectiveness of child–parent interven- tions compared to child-focused interventions in the treatment of childhood anxiety disorders. Although prior reviews have examined the effects of interventions for childhood anxiety dis- orders, these reviews primarily focused on individual and/or cognitive behavioral interventions, did not use a systematic methodology or meta-analytic techniques, included diagnostic classifications beyond anxiety disorders, or were conducted before recent advancements in the field (see Cartwright- Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Creswell & Cartwright-Hatton, 2007; In-Albon & Schneider, 2007; Ishikawa, Okajima, Matsuoka, & Sakano, 2007; James, Soler, & Weatherall, 2009; King et al.,1998; Reynolds, Wilson, Austin, & Hooper, 2012; Silverman, Pina, & Viswesvaran, 2008). In light of the advancements made in understanding and treating childhood anxiety disorder in the past decade and the plethora of child–parent interventions being developed and used, this review examines the current state of child–parent intervention research for treating childhood anxiety disorders and improves upon prior reviews by using systematic review 2 Research on Social Work Practice 00(0) at SAINT LOUIS UNIV on September 20, 2013rsw.sagepub.comDownloaded from http://rsw.sagepub.com/ methods and meta-analytic techniques to provide a comprehen- sive picture of effects. Purpose of the Present Study The purpose of this systematic review and meta-analysis is to specifically examine the differential effect on anxiety out- comes of child–parent interventions compared to child- focused interventions for children with anxiety disorders. The specific research questions guiding this study were as follows: (1) Are child–parent interventions more effective than inter- ventions involving solely the child in decreasing anxiety for children with anxiety disorders? and (2) Are there differences in magnitude of effects by type of child–parent intervention? Method Systematic review procedures, following the Campbell Colla- boration guidelines (see www.campbellcollaboration.org), were used for all aspects of the search, retrieval, selection, and coding of published and unpublished studies meeting study inclusion criteria. Meta-analytic techniques were employed to quantita- tively synthesize the results from included studies. The protocol and screening and coding instruments guiding the conduct of this study are available from the first author upon request. Study Eligibility Criteria Studies were eligible for inclusion if they examined the effects of a child–parent intervention (i.e., an intervention in which a parent or guardian and child were directly involved in the treat- ment) against the effects of interventions targeting only the child (an individual or group intervention in which the parent did not directly participate) for children under the age of 18 with at least one anxiety disorder. Interventions were consid- ered a child–parent intervention if they included at least one intergenerational family unit, that is, parent and child or pri- mary caretaker and child. Studies must have employed a rando- mized or quasi-experimental design, measured at least one anxiety outcome, and reported sufficient information to calcu- late an effect size. Published and unpublished studies were eli- gible and no geographical restrictions were imposed; however, this review was limited to English language reports of studies conducted between 1980 and 2013. Search Strategy A comprehensive and systematic search strategy was conducted in an attempt to identify and retrieve all relevant published and unpublished studies meeting inclusion criteria. The search, com- pleted in April 2013, involved several sources and used the follow- ing key words: ‘‘anxiety disorders,’’ ‘‘family therapy,’’ ‘‘childhood anxiety,’’ ‘‘family treatment,’’ ‘‘randomized,’’ ‘‘experimental,’’ ‘‘quasi-experimental,’’ ‘‘clinical,’’ and ‘‘intervention.’’ Informa- tion sources included seven electronic databases (PsychINFO, Pro- Quest, Dissertations and Abstracts, Academic Search Premier, Social Work Abstracts, PubMed, and Medline); personal contacts with the first authors of all relevant studies, relevant researchers, research institutes, and professional associations; hand searches of journals relevant to the topic of the review (i.e., Journal of Mar- riage and Family Therapy, Journal of the American Association of Child and Adolescent Psychiatry, The American Journal of Orthopsychiatry, and Psychiatric Services); online searches through Google, Google Scholar, Yahoo!, and relevant websites of professional organizations; and reference lists of prior reviews and included studies. Study Selection and Coding Procedures The first author screened titles and abstracts for relevance. Those that were obviously ineligible (i.e., did not involve the target population, did not involve a child–parent intervention, or were theoretical in nature) were screened out. The full text of all studies that were not obviously ineligible or were ques- tionable at this stage was obtained and screened for eligibility, using a screening instrument developed by the first author. The first author and a trained graduate student then coded stud- ies deemed eligible by using a coding instrument developed by the authors to guide systematic examination and extraction of data. The coding instrument included categories concerning all relevant bibliographic information, study context, intervention and sample descriptors, research methods and quality descrip- tors, and effect size data (Lipsey & Wilson, 2001). To ensure reliability of coding procedures, the first author and a trained graduated student independently coded 100% of the studies. Interrater reliability was obtained by dividing the number of agreements by the number of possible agreements for each study. There was 98% agreement between the two coders. All discrepancies were discussed and resolved. Statistical Methods Statistical analysis was designed to produce descriptive information on the characteristics of the included studies, the effect size of each intervention on anxiety outcomes, the grand mean effect size, and the heterogeneity of effect sizes around the mean. The standard mean difference effect size statistic, corrected for small sample size bias (Hedges’ g), was calculated for each study using a statistical software package, Comprehensive Meta-Analysis, Version 2.0 (Borenstein, Hedges, Higgins, & Rothstein, 2005) by inputting the means, standard deviations, and sample sizes for the treatment and control groups reported by the primary study authors. To main- tain statistical independence of data, only one effect size was computed for each subject sample. Four of the eight studies used multiple measures to assess anxiety. In cases where mul- tiple measures were used, the most valid measure was selected. In two cases, the measure used in the meta-analysis included both a parent and child report, which were reported by the pri- mary study authors together as one score. In cases where more than one comparison group was used (i.e., a waitlist control and an alternative treatment), the group that received the alternative child-focused treatment was used in the analysis. Brendel and Maynard 3 at SAINT LOUIS UNIV on September 20, 2013rsw.sagepub.comDownloaded from http://rsw.sagepub.com/ The effects of included studies were quantitatively synthe- sized in Comprehensive Meta-Analysis. Effect sizes were inverse variance weighted and random effects statistical mod- els were assumed. Cochrane’s Q was used to assess heteroge- neity in the effect sizes. A significant Q rejects the null hypotheses, indicating that the variability in effect sizes between studies is greater than what would be expected from sampling error alone (Hedges & Olkin, 1985). Moderator anal- ysis was not indicated, as the statistical test assessing heteroge- neity was not significant (Lipsey & Wilson, 2001). We had planned to assess and report publication bias by constructing a scatter plot of study effect size by sample size; however, due to the small number of studies, and thus low power, the use of funnel plots or other techniques such as regression to assess publication bias was not indicated (Card, 2012). Results The search procedures yielded close to 300 titles. After review of titles and abstracts, 33 potential studies were retrieved in full text for screening. Of those, 15 reports were excluded due to not meeting basic eligibility criteria and the remaining 18 reports were fully coded. Of those 18 studies, 10 were deemed ineligi- ble. These studies were excluded due to using a single-group pretest–posttest design (n ¼ 6), reporting secondary results of included studies (n ¼ 2), or not providing sufficient statistics to compute an effect size (n ¼ 2). The final sample for this review includes eight randomized controlled trials. See Figure 1 for a flowchart detailing the search and selection process. Descriptive Analysis The characteristics of the eight included studies are summar- ized in Table 1. Of the eight studies, one was an unpublished dissertation and seven were peer-reviewed journal articles. The studies were conducted in four countries: the United States (n ¼ 4), Australia (n ¼ 2), Canada (n ¼ 1), and the Netherlands (n ¼ 1). The majority of the studies were conducted in a clinic setting (n ¼ 7), and one was conducted in a hospital setting. Across the eight studies, participants included a total of 710 children and at least one parent. The age range of child partici- pants was wide across studies (n ¼ 1, 6–13 years; n ¼ 1, 6–16 years; n ¼ 1, 7–12 years; n ¼ 3, 7–14; n ¼ 1, 12–17 years; n ¼ 1, 8–17 years). No studies included a subgroup analysis by age range. Studies included a balanced proportion of male and female child participants. Most of the participants across the eight studies were Caucasian (68%), and 91% of the partici- pants had a primary diagnosis of social phobia, SAD, or gener- alized anxiety disorder. Approximately 98% of the participants Figure 1. Study search and selection process flow chart. RCT ¼ randomized controlled trial. 4 Research on Social Work Practice 00(0) at SAINT LOUIS UNIV on September 20, 2013rsw.sagepub.comDownloaded from http://rsw.sagepub.com/ had a secondary diagnosis, with the vast majority of secondary diagnoses (83%) being another anxiety disorder. All child–parent interventions in this review used a treat- ment manual and were based on FCBT; the comparison group interventions were either individual CBT with the child (n ¼ 7) or group CBT with children only (n ¼ 1). All interventions were delivered in 12 to 16 sessions of 60 to 90 minutes each. Four included studies tested Coping Cat (Kendall & Hedtke, 2006) or adaptations of Coping Cat, including a modified Coping Cat for adolescents (Siqueland, Rynn, & Diamond, 2005), Coping Koala (Barrett, Dadds, & Rapee, 1991), and Coping Bear (Men- dlowitz & Scapillato, 1996). Coping Cat is a manualized cogni- tive behavioral treatment program that assists school-age children in recognizing and coping with anxious feelings and physical reactions to anxiety. Wood, Piacentini, Southam- Gerow, Chu, and Sigman (2006) examined the Building Confi- dence Program, developed specifically for their study. This inter- vention involved combining child-focused cognitive behavioral therapies with in vivo exposure and parent involvement. Spence, Donovan, and Brechman-Toussaint (2000) used the Social Skills Training: Enhancing Social Competence in Children and Adoles- cents program. The program integrated CBT, social skills train- ing, relaxation techniques, problem-solving, and exposure interventions. The parent–child interventions in the remaining three studies were not named, but all used manualized cognitive behavioral interventions developed for their studies. At least one doctoral level therapist or psychiatrist delivered all interventions. Other treatment personnel included doctoral students in five studies, one social worker, eight research assistants (in a single study), one family therapist, one youth care worker, and other unspecified master’s and doctoral level clinicians. Six studies used a combination of trained clinicians. Meta-Analytic Results The grand mean effect size for anxiety outcomes from the eight independent samples reported in the included studies, assuming a random effects model, was 0.26 (95% confidence interval [0.05, 0.47], p < .05), demonstrating a small but positive and statistically significant effect, favoring child–parent interven- tions on anxiety outcomes. Table 2 provides a summary of the characteristics and mean effect sizes for each of the included studies. The mean effect size and confidence intervals for each study are also shown in the forest plot in Figure 2. As seen in the table and forest plot, the effect sizes range from a very small and negative 0.01 to .88. Moreover, the confidence intervals around the mean effect size in seven of the eight studies cross zero, indicating that the child–parent intervention group did not differ significantly on anxiety outcomes from the child-focused intervention group. However, when the studies are pooled, the mean effect is positive, small, and statistically significant. Analysis of Homogeneity. To examine whether between-study var- iance is greater than what would be expected from sampling error alone, an analysis of heterogeneity was conducted using the Q-test. The result of the test of homogeneity was not significant (Q ¼ 8.08, df ¼ 7, p ¼ .325, I2 ¼ … Contents lists available at ScienceDirect Internet Interventions journal homepage: www.elsevier.com/locate/invent Guided internet-based cognitive behavioral therapy for adolescent anxiety: Predictors of treatment response Silke Stjerneklar⁎, Esben Hougaard, Mikael Thastum Department of Psychology and Behavioral Sciences, Aarhus BSS, Aarhus University, Bartholins Allé 9, 8000 Aarhus C, Denmark A R T I C L E I N F O Keywords: Anxiety disorders Internet-based Cognitive behavioral therapy Adolescents Predictors Treatment response A B S T R A C T Background: Guided internet-based cognitive behavioral therapy (ICBT) has been found efficacious in reducing symptoms of anxiety in adolescents with anxiety disorders, but not all respond equally well. Objective: In this study, we explored candidate predictors of ICBT treatment response within the frame of a randomized controlled trial. Methods: Sixty-five adolescents (13–17 years) with anxiety disorders according to DSM-IV received 14 weeks of therapist-guided ICBT. Outcome was evaluated as improvement (continuous change score) from pre-treatment to 12-month follow-up according to self-reported anxiety symptoms and clinician-rated diagnostic severity. Clinical predictors included baseline self- and parent-reported anxiety symptom levels, baseline clinician-rated severity of primary diagnosis, summed baseline clinician-rated severity of all anxiety diagnoses, baseline self-rated de- pressive symptoms, age of onset, and primary diagnosis of social phobia. Demographic predictors included age, gender and computer comfortability. Therapy process-related predictors included number of completed modules and therapist phone calls, summed duration of therapist phone calls, degree of parent support, and therapeutic alliance. Multi-level models were used to test the prediction effects over time. Results: Higher levels of self- and clinician-rated baseline anxiety and self-rated depressive symptoms, female gender, and higher levels of computer comfortability were associated with increased treatment response. None of the proposed therapy process-related predictors significantly predicted treatment response. Conclusion: The present findings indicate that ICBT may be an acceptable choice of treatment for youths, even those with relative high levels of anxiety and depressive symptoms. 1. Introduction Anxiety is one of the most common mental health disorders af- fecting 5–12% of youths from western cultures (Beesdo et al., 2009; Costello et al., 2011). When left untreated, anxiety disorders are asso- ciated with persistent difficulties and long-term consequences inter- fering with general development (Langley et al., 2004), social func- tioning (La Greca and Harrison, 2005; Wood and McLeod, 2008) and academic achievements (Essau et al., 2000). Treatment studies of adolescents with anxiety disorders have proven face-to-face cognitive behavioral therapy (CBT) to be highly effective in reducing anxiety symptoms (Cartwright-Hatton et al., 2004; James et al., 2013; Reynolds et al., 2012). However, it has been estimated that only around 25% of clinically anxious youths receive treatment (Essau et al., 2000; Wang et al., 2007) as their access to health care services is often limited (Gulliver et al., 2010; Stallard et al., 2007). Adolescents may be especially reluctant to seek professional help for mental health issues due to a variety of health care barriers such as concerns about con- fidentiality, fear of social stigma, and worries concerning costs and transportation (Booth et al., 2004; Elliott and Larson, 2004; Gulliver et al., 2010; Rickwood et al., 2007). As means to increase access to and reduce costs of psychological interventions, internet-based CBT (ICBT) has been proposed, and re- search shows promising results for the ICBT treatment of adolescents with anxiety disorders (Ebert et al., 2015; Pennant et al., 2015; Podina et al., 2016; Stjerneklar et al., submitted for publication). However, a considerable proportion of anxious adolescents re- ceiving ICBT do not, or only partially, respond to treatment; and non- response at follow-up (FU) from recent randomized controlled trials (RCTs) range from 38 to 68% (Lenhard et al., 2017; Spence et al., 2011; Stjerneklar et al., submitted for publication; Tillfors et al., 2011), mir- roring results reported from regular CBT of 40–50% non-responders https://doi.org/10.1016/j.invent.2019.01.003 Received 2 July 2018; Received in revised form 15 January 2019; Accepted 17 January 2019 ⁎ Corresponding author at: Dep. of Psychology and Behavioral Sciences, Aarhus BSS, Aarhus University, Bartholins Allé 13, building 1343, room 393, 8000 Aarhus C, Denmark. E-mail address: [email protected]y.au.dk (S. Stjerneklar). Internet Interventions 15 (2019) 116–125 Available online 31 January 2019 2214-7829/ © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). T http://www.sciencedirect.com/science/journal/22147829 https://www.elsevier.com/locate/invent https://doi.org/10.1016/j.invent.2019.01.003 https://doi.org/10.1016/j.invent.2019.01.003 mailto:[email protected] https://doi.org/10.1016/j.invent.2019.01.003 http://crossmark.crossref.org/dialog/?doi=10.1016/j.invent.2019.01.003&domain=pdf (James et al., 2015; Silverman et al., 2008). Knowledge of predictors of treatment response may help clinicians identify adolescents at risk of low response before they commend therapy and guide the development and refinement of more effective interventions (Hudson et al., 2015a; Rapee, 2000; Steketee and Chambless, 1992). Few pre-treatment patient predictors in face-to-face CBT with chil- dren and adolescents with anxiety disorders have been consistently demonstrated (Knight et al., 2014; Lundkvist-Houndoumadi et al., 2014). Pre-treatment predictors most consistently associated with poorer response are higher baseline symptom severity, social phobia (SoP) as primary anxiety disorder, comorbid externalizing and/or de- pressive symptoms, and parental psychopathology (Hudson et al., 2015a; Knight et al., 2014; Lundkvist-Houndoumadi et al., 2014; Rapee et al., 2009). Although an association between higher age and outcome has been documented (Reynolds et al., 2012), a large meta-analysis with individual patient data found no age effects (Bennett et al., 2013). Despite the assumption that the therapeutic mechanisms underlying regular CBT and ICBT are the same, there are important differences between the two therapy formats possibly influencing both the kind, strength and direction of factors predicting treatment response. For example, adolescents receiving ICBT typically have less therapist gui- dance than those receiving regular CBT and the modality in which this guidance is offered differs (i.e., physical presence versus telephone calls or emails). Given the physical absence of a therapist, ICBT most likely demands more self-discipline from the adolescents as well as greater responsibility for the implementation of learned techniques than CBT. It is therefore relevant to investigate factors that may predict treatment response specifically in ICBT. Research within ICBT for adults with anxiety disorders has con- sistently demonstrated higher baseline symptom severity (El Alaoui et al., 2013; Hadjistavropoulos et al., 2016; Hedman et al., 2012; Hedman et al., 2013) and higher adherence (i.e. number of completed modules) (Berger et al., 2014; El Alaoui et al., 2015; Hadjistavropoulos et al., 2016; Hedman et al., 2012; Hedman et al., 2013), to predict better treatment response. Mixed results have been found when in- vestigating the predictive effect of baseline depressive symptoms. Two trials (Hedman et al., 2012; Hedman et al., 2013) have reported sig- nificant negative associations with outcome, whereas one trial (El Alaoui et al., 2015) reported no association. Similarly, mixed results have been demonstrated for computer comfortability with two studies (Hedman et al., 2012; Hedman et al., 2013) demonstrating level of computer skills not to be associated with outcome, and one study (Hadjistavropoulos et al., 2016) demonstrating ‘comfortability with written communication’ to be positively associated with treatment re- sponse. Within adult face-to-face psychotherapy research, the therapeutic alliance is the most studied process variable with a mean correlation with outcome of 0.28 in a large meta-analysis (Horvath et al., 2011). Alliance-outcome associations among youths have generally lead to somewhat smaller correlations as shown by two meta-analyses that also both found lower correlations for adolescents (0.10 and 0.19) than for children (McLeod, 2011; Shirk et al., 2011). The therapeutic alliance has been investigated within ICBT for adults suggesting that even minimal therapist contact is sufficient to establish an adequate alliance (Andersson et al., 2012; Cuijpers et al., 2010). Although a recent nar- rative review of the alliance in internet-based psychotherapy reported client-rated alliance scores roughly equivalent to those found in face-to- face therapy, mixed results have been found for alliance-outcome as- sociations (Berger, 2017). Gender (Berger et al., 2014; El Alaoui et al., 2013; El Alaoui et al., 2015; Hadjistavropoulos et al., 2016; Hedman et al., 2012; Hedman et al., 2013) and age of onset (El Alaoui et al., 2013; El Alaoui et al., 2015; Hedman et al., 2012) have previously failed to predict outcome in ICBT for adults. Despite that therapist involvement has generally been shown to substantially increase program usage and improve the efficacy of ICBT with adults when compared with self-help interventions with no therapist support (Christensen et al., 2009; Spek et al., 2007), previous studies of various degrees of therapist support (i.e., number of telephone calls, number of messages sent by therapist and patient, and therapist time) as predictors has failed so far to de- monstrate significant associations (Berger et al., 2014; El Alaoui et al., 2015; Hadjistavropoulos et al., 2016). Only few studies have investigated pre-treatment patient predictors of treatment response within ICBT for adolescents with anxiety dis- orders. Three meta-analyses of ICBT for children, adolescents and younger adults (age range 5–25) with anxiety disorders (Ebert et al., 2015; Pennant et al., 2015; Podina et al., 2016) concurrently found superior results for older youths compared to younger indicating age to predict treatment response. Furthermore, (Ebert et al., 2015) in- vestigated parental involvement (‘yes/no’) and did not find support for a predictive relationship. Anderson et al. (2012) studied the role of working alliance in predicting treatment outcome for children and adolescents (age 7–18) with anxiety disorders and found adolescents, but not children, to improve significantly more in overall functioning when alliance was higher (beta = 0.22, t79 = 2.21, P = 0.03). Of two more recent studies, Lenhard et al. (2017) examined the effect of an ICBT program for adolescents (age 12–17) with OCD and found no association between number of completed modules and outcome while Spence et al. (2017) in their study on generic versus disorder specific ICBT for youths (age 8–17) with social anxiety disorder found a sig- nificant positive association between number of completed sessions and reductions in anxiety symptoms and improvements in functioning. However, this association was only significant for children – not for adolescents. To the best of our knowledge, no previous studies of ICBT has looked at the predictive value of primary diagnosis within anxiety disorders, e.g. whether having been diagnosed with SoP as primary diagnosis significantly predicts treatment outcome compared to other anxiety diagnoses. 1.1. Aim and hypotheses The aim of the present study was to explore a range of candidate predictors of treatment response within ICBT for adolescents. More specifically, we investigated clinical (baseline anxiety symptom se- verity, baseline depressive symptoms, a primary diagnosis of SoP, and age of onset), demographic (age, gender and computer comfortability), and therapy process-related predictors (number of completed modules, number of therapist calls, total call duration, degree of parental sup- port, and therapeutic alliance). Based on previous results, we hy- pothesized that higher baseline symptom severity, higher age (within the range 13 to 17), more completed modules, as well as higher ther- apeutic alliance scores would predict larger improvements, while more baseline depressive symptoms, a primary diagnosis of SoP, and low computer comfortability would predict less improvement. Due to the limited research on age of onset, gender, and degree of parent- and therapist support as candidate predictors, these analyses were con- sidered exploratory. 2. Methods 2.1. Participants and recruitment The study took place at the Centre for Psychological Treatment of Children and Adolescents (CEBU), a research and teaching facility at the Department of Psychology and Behavioral Sciences, Aarhus University, Denmark. Participants in the study were 65 adolescents who received ICBT treatment within the context of a previous randomized controlled trial (Stjerneklar et al., submitted for publication; ClinicalTrials.gov: NCT02535403). Inclusion criteria were as follows: (a) age between 13 and 17 years; (b) a primary anxiety diagnosis ac- cording to the Diagnostic and Statistical Manual of Mental Disorders, 4th S. Stjerneklar et al. Internet Interventions 15 (2019) 116–125 117 http://ClinicalTrials.gov http://clinicaltrials.gov/show/NCT02535403 ed. (DSM–IV; American Psychiatric Association, 1994); (c) access to a home computer with internet; and (d) ability to write and read in Danish. Criteria of exclusion were: (a) severe comorbid depression (CSR > 5); (b) substance abuse; (c) severe self-harm or suicidal idea- tion; (d) pervasive developmental disorder; (e) intellectual disability; (f) learning disorder; and (f) psychotic symptoms. A detailed descrip- tion of RCT study procedures are found elsewhere (Stjerneklar, Hougaard, McLellan, & Thastum, submitted for publication). Upon the return of a signed consent form, 70 families were included in the pre- vious RCT and randomly allocated to 14 weeks of ICBT treatment (n = 35) or a WL group (n = 35). Having waited for 14 weeks, families in the WL group recompleted questionnaires, took part in a second diagnostic interview, and were offered ICBT treatment identical to the one participants in the ICBT group had completed. Four participants from WL declined treatment and dropped out before their second as- sessment (the baseline assessment of the present study); additionally, one had improved during the WL period and did not meet criteria for any diagnoses at baseline. This participant decided to complete treat- ment, but was excluded from the present study. The study was ap- proved by the local Ethics Committee of Central Denmark Region (1-10- 72-98-15) and by the Danish Data Protection Agency. 2.2. Measures 2.2.1. Outcome measures 2.2.1.1. The Anxiety Disorders Interview Schedule. Type and severity of anxiety disorders was assessed using the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version (ADIS-IV C/P; Silverman and Albano, 1996). ADIS-IV is a semi-structured diagnostic interview, which in this study was conducted by graduate psychology students with the adolescent and one parent (usually the mother) separately to evaluate the diagnostic criteria of anxiety disorders in accordance with DSM-IV (American Psychiatric Association, 1994). Assembling information from both informants, the severity of diagnoses - the Clinical Severity Rating (CSR) – was assessed by a clinical psychologist on a nine-point Likert scale (0 = not at all disturbing; 8 = severely disturbing). A CSR of ≥ four represent clinical level of impairment, whereas scores below four are considered subclinical. Where symptom criteria for several diagnoses were met, the one with the highest CSR or judged most disturbing by the assessor was considered the primary diagnosis. The ADIS-IV has well-established psychometric properties (Silverman et al., 2001; Wood et al., 2002). High inter-rater reliability and validity of the ADIS-IV administered over the telephone has been demonstrated, comparable to those administered face-to-face (Lyneham and Rapee, 2005). Interrater- reliability (Cohen's Kappa), as calculated in the RCT (Stjerneklar et al., submitted for publication), for primary anxiety diagnoses was excellent, K = 0.80. The intra-class correlation coefficient (ICC; two- way random for individual raters, consistency) was fair, ICC = 0.419 (95% CI: -0.121–0.768; p = 0.060), for the CSR of primary anxiety diagnosis (CSRprim), and good, ICC = 0.73 (95% CI: 0.348–0.905; p = 0.001) for the summed CSR of all anxiety diagnoses (CSRall) when calculated in the RCT (Stjerneklar et al., submitted for publication). Please note that only the summed CSR of all anxiety diagnoses was used as outcome measure in the present study. 2.2.1.2. The Spence Children's Anxiety Scale. Adolescent- and parent- reported anxiety symptoms were assessed using the Spence Children's Anxiety Scale: Child and Parent Version (SCAS-C/P; Spence, 1998). The SCAS contains 38 items rated on a four-point Likert scale from zero to three, with higher scores indicating higher anxiety symptom levels. The questionnaire is administered separately to the adolescent (SCAS-C) and to parents (SCAS-P). The Danish version of SCAS has demonstrated good to excellent internal consistency and good test-retest reliability (Arendt et al., 2014). Internal consistency (Cronbach's alpha) in the current study was excellent for both the adolescent (α = 0.90) and parent version (α = 0.90). Please note that only the SCAS-C and not the SCAS-P was used as outcome measure. 2.2.2. Measures of predictors The CSRprim and CSRall were assessed with the ADIS-IV. Self-rated depressive symptoms were measured with The Short version of the Moods and Feelings Questionnaire (S-MFQ; Angold et al., 1995). The S-MFQ measures depressive symptoms within the last two weeks through 13 items rated on a three-point Likert scale (0 = not true; 2 = true). The S- MFQ has demonstrated good psychometric properties (Angold et al., 1995). In the present study, internal consistency was excellent (α = 0.92). Age of onset of anxiety symptoms was derived from the mother pre-treatment questionnaire with the question: At what age did you first notice your child being more anxious than other children? Demographic data were collected through the online pre-treatment questionnaires. Participants' computer comfortability was measured with the question: How comfortable do you feel using the computer and the internet? rated on a four-point Likert scale (1 = not comfortable at all; 4 = very comfortable). A module was defined as complete when 80% or above of the core module components (i.e., instructions, example-videos and practice tasks excluding worksheets) had been activated according to website server logs. Number and duration of therapist phone calls was calcu- lated from participant records. Only actual conversations (i.e., no missing calls) were included in the analyses. Degree of parent support was derived from the mother post-treatment questionnaire with the question: On average, how much time have you spent weekly helping your teen complete the program? Therapeutic alliance was assessed with The Working Alliance Inventory-Short Form (WAI-S; Tracey and Kokotovic, 1989). The WAI-S is a 12-item version of the original 36-item WAI (Horvath and Greenberg, 1989) measuring the therapeutic alliance between therapist and adolescent as reported by the adolescent. Items are rated on a seven-point Likert scale (1 = never; 7 = all the time). The ques- tionnaire contains three subscales in agreement with Bordin's (1979) alliance concept: therapeutic bond, agreement on therapeutic goals, and agreement on therapeutic tasks. In the present study, only the total scale was used. The scale has demonstrated good psychometric prop- erties, with a Cronbach's alpha of α = 0.93 for the total scale (Tracey and Kokotovic, 1989). Internal consistency in the present study was α (week four) = 0.92; α (week eight) = 0.94; α (post) = 0.94. Diagnostic status was assessed at baseline (pre), after the interven- tion (post), and at three-month FU. All diagnostic interviews were re- corded using Crystal Gears® Ver. 2.00 RTM. Fourteen (20%) of the 35 ICBT pre-interviews were re-assessed for inter-rater reliability purposes. The 14 interviews were selected from the top of a random list of all pre- interviews, created with an online list randomizer using atmospheric noise. Adolescents and their parents received the online self-report questionnaires at pre, post, three- and twelve-month FU. For the pur- pose of the present study, only the adolescents' and mothers' responses were used. The therapeutic alliance questionnaire (WAI-S) was ad- ministered at week four and eight of treatment as well as at post- treatment. All questionnaires were administered through an electronic data collection platform, SurveyXact. 2.3. Treatment ChilledOut Online is based on the Cool Kids and Chilled treatment programs developed at Macquarie University, Sydney, Australia (Lyneham et al., 2014). The program teaches CBT inspired anxiety management strategies for adolescents through eight online modules of approximately 30 min each, with a focus on psychoeducation, cognitive restructuring, goal setting, and graded exposure. Program content is provided through a combination of multimedia formats such as text, audio, illustrations, and video vignettes. Within each module, adoles- cents are presented with different worksheets and homework practice S. Stjerneklar et al. Internet Interventions 15 (2019) 116–125 118 tasks that they are encouraged to keep working on when they are not in front of the computer. Adolescents were advised to complete all mod- ules within the intervention period of 14 weeks, after which they would have another three months of web site access. Adolescents received a weekly phone call from a trained graduate student therapist focusing on problem solving, technical assistance, feedback about homework tasks, and encouragement. At three-month FU, adolescents received a booster phone call from the therapist mainly addressing motivation and consolidation of previously learned skills. Parents received the ChilledOut Parent Companion handout before treatment start describing the program's core treatment strategies and advising them on how to best support their teenager throughout the intervention. Additionally, parents received an introductory phone call from the therapist within the first two weeks of treatment. Further treatment details are provided elsewhere (Stjerneklar et al., submitted for publication; Stjerneklar et al., 2018). 2.4. Statistical analyses The present study employed a repeated measurements design ex- amining the following predictors of treatment response: Clinical char- acteristics including baseline self- and parent-reported anxiety symptom levels (SCAS-C/P), baseline CSRprim, summed baseline CSRall, baseline self-rated depressive symptoms, age of onset, and primary di- agnosis of SoP. Demographic characteristics including age, gender and computer comfortability. Therapy process-related variables including number of completed modules, number of therapist phone calls, summed duration of therapist phone calls, degree of parent support, and therapeutic alliance. Predicted outcome was evaluated as (a) change score in summed severity of all anxiety diagnoses (CSRall) from pre to 3-month FU, and (b) change in self-reported anxiety symptoms (SCAS-C) from pre to 12-month FU. Analyses that included the same variable as both predictor and outcome/criterion (i.e., CSRall/CSRall, CSRprim/CSRall, and SCAS-C/SCAS-C) were omitted from the study to prevent overlap. Mixed linear models (MLMs) were used to test candidate predictors over time, i.e. time × predictor with all measuring points included in the analyses. As MLMs tolerate missing values without compromising power, all analyses were based on the intention-to-treat sample (N = 65) without imputations of missing values; a method re- commended over other procedures in longitudinal clinical trials (Chakraborty and Gu, 2009). Data were hierarchically arranged in two levels, with time at Level 1 nested within individuals at Level 2. MLMs were estimated with the full maximum likelihood method, and depen- dent variables were treated as continuous. Models included a random intercept, and the slope was specified as random if it significantly im- proved model fit as evaluated by a change in the –2LL fit statistics (Heck et al., 2014). A candidate variable was considered a predictor if the two-way interaction term was statistically significant. As suggested when assessing single predictors using multiple measurement tools (Knight et al., 2014), Bonferroni adjustments were used to correct for family-wise analysis error. Candidate predictors were analyzed with two different outcome measures, thus statistical significance was de- fined as p ≤ 0.025 (0.05/2) with a two-tailed significance level. Effect sizes were expressed as Cohen's d derived from the F-test, calculated as d = 2 × √(F / df). All analyses were carried out using IBM® SPSS® sta- tistics, v.24.0 (Armonk, NY: IBM Corp.). All candidate predictors were included in the analyses as continuous variables. For illustration purposes, variables found to significantly predict treatment response were dichotomized according to the median when graphically depicted. Although in the original RCT, modest symptom improvements were observed among WL participants while on waitlist (as reported in Stjerneklar et al., submitted for publication), no significant differences in treatment effect over time were found between the two conditions on any of the included outcome measures (p = 0.326–0.954). Thus, all predictor analyses were conducted using data from the pooled sample of 65 participants. Post hoc power calculations based on ANOVA (re- peated measures) indicated that a sample size of 65 and an error probability of α = 0.05 (two-tailed) would have sufficient power (0.80) to detect an effect size of d = 0.70. 3. Results 3.1. Study flow and sample characteristics The degree of missing data (intention-to-treat sample, N = 65) was as follows: ADIS (pre = 0; post = 2; 3-month FU = 9); SCAS-C (pre = 1; post = 9; 3-month FU = 16; 12-month FU = 18), and SCAS-P (pre = 0; post = 4; 3-month FU = 6; 12-month FU = 14). Reasons for non-completion are largely unknown, as most non-completers could not be reached. Baseline sample characteristics are presented in Table 1. The 65 participants (78% females) had a mean age of 15.2 (SD = 1.33; range 13–17). The most common primary diagnosis was SoP (42%), followed by GAD (14%), separation anxiety disorder (11%), specific phobia (9%), and obsessive-compulsive disorder (OCD) (9%). The remaining participants met criteria for panic disorder, with (5%) or without (5%) agoraphobia, or agoraphobia without a history of panic disorder (6%). Mean number of anxiety diagnoses per adolescent was 2.1 (SD = 1.01). Regarding participants' computer comfortability, thirty-four (52%) re- ported feeling ‘very comfortable’ using computer and internet, 28 (43%) reported feeling ‘fairly comfortable’, two (5%) reported feeling only ‘a little comfortable’, and none reported ‘not at all comfortable’, Table 1 Sample characteristics. Continuous variables N Mean SD Age (years) 65 15.2 1.33 Age of onset 65 8.6 4.32 SCAS-C total 64 43.8 17.01 SCAS-P total 65 44.7 16.94 CSR primary diagnosis 65 6.4 0.86 CSR all anxiety diagnoses 65 12.0 5.62 S-MFQ 64 9.3 6.86 Number of anxiety diagnoses 65 2.1 1.01 Number of completed modules 65 6.4 2.02 Number of therapist calls 65 10.4 2.80 Summed call duration (hours) 65 3.1 1.33 Computer comfortability 65 3.5 0.59 Dichotomous variables N Frequency Percentage Gender (female) 65 51 78 Primary diagnosis Social phobia 65 27 42 Generalized anxiety disorder 65 9 14 Separation anxiety disorder 65 7 11 Specific phobia 65 6 9 Obsessive compulsive disorder 65 6 9 Agoraphobia without a history of panic disorder 65 4 6 Panic disorder without agoraphobia 65 3 5 Panic disorder with agoraphobia 65 3 5 Comorbid mood disorder 65 4 6 Degree of parental assistancea No time 61 7 11 0–10 min 61 17 28 10–30 min 61 13 21 30–60 min 61 16 26 1–2 h 61 4 7 2–5 h 61 3 5 > 10 h 61 1 2 Note: SCAS-C: Spence Children's Anxiety Scala, Child version; SCAS-P: Spence Children's Anxiety Scale, Parent version; CSR: Clinical Severity Rating; S-MFQ: Short version of the Mood and Feelings Questionnaire. a Weekly average. S. Stjerneklar et al. Internet Interventions 15 (2019) 116–125 119 resulting in a mean rating of M = 3.5 (SD = 0.59). Participants (in- tention-to-treat, N = 65) completed a mean of 4.6 modules (SD = 2.67) and received a mean of 10.4 therapist calls (SD = 2.80) with an average summed call duration of 3.1 h (SD = 1.33). 3.2. Clinical predictors Results are presented in Table 2. Higher self-reported baseline an- xiety symptoms (SCAS-C) predicted larger …