Stepped care for anxious youth
What was the aim of this research?
A stepped care system offers a series of treatments, from least intensive with fewer resources needed to conduct the treatment such as printed or online self-help material, through to most intensive where tailored face-to-face individual treatments are offered. In a stepped care approach the individual starts their treatment with the least intensive option, only stepping up to more intense treatment if needed.
Stepped care is considered the best value model for delivering evidenced based treatment, however minimal research has been conducted to evaluate its efficacy and value. This study evaluated the efficacy and therapy resources used by cognitive behavioural therapy (CBT) for child anxiety delivered via a stepped-care framework versus a standard evidence based (CBT) treatment program.
How did we do it?
281 youth with anxiety disorders aged 7 to 17 years were randomly allocated to receive either a stepped care treatment OR a 10 session, 60 minute per session, evidence based (CBT) intervention (Cool Kids).
Stepped Care involved: 1) low intensity treatment (assisted self-help) which included minimal interaction with a clinician, 2) standard CBT with flexibility in the number of sessions based on individual progress and 3) individually tailored treatment.
In the stepped care approach it was the family that determined if treatment should stop or progress to the next level with feedback from the clinician to guide decision making.
What did we find?
After one year, around 75% of youth in both treatments were free of their presenting disorder. So outcomes were similar regardless of whether a stepped care approach was taken or the child completed the standard evidence based treatment program. However, total therapist time spent per child was significantly less when delivering stepped care compared with the standard best practice treatment. The best outcomes where found for those who completed the first two steps in the stepped care model (i.e. low intensity and standard CBT). These youth were almost as likely to be diagnosis-free, but at a fraction of the cost.
Those who moved onto step 3 and required more intense tailored treatment were less likely to be disorder free at 12 months after the completion of treatment compared to those who reached the end of their treatment at step 2. Yet the amount of therapist time provided to those who completed step 3 was significantly more than those provided to clients who completed only step 1 or 2.
What does this mean in practice?
Based on this study – the first of its kind - employing a stepped care approach, and restricting stepped care to only steps 1 and 2, will use far less therapist time and lead to major cost savings to current best practice (standard, empirically validated CBT package) while still allowing similar outcomes.
As this study is the first of its kind more research should be undertaken to confirm this finding.
Citation: Rapee, R.M, Lyneham, H. J, Wuthrich, V., Chatterton, M.L., Hudson, J. L., Kangas, M., Mihalopoulos, C. (2017), Comparison of Stepped Care Delivery Against a Single, Empirically Validated Cognitive-Behavioral Therapy Program for Youth With Anxiety: A Randomized Clinical Trial, Journal of the American Academy of Child & Adolescent Psychiatry DOI: 10.1016/j.jaac.2017.08.001