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Cathy Creswell 1,*, Susan Cruddace 1, Stephen Gerry 2, Rachel Gitau 1, Emma McIntosh 3, Jill Mollison 4, Lynne Murray 1,5, Rosamund Shafran 6, Alan Stein 7,8, Mara Violato 9,10, Merryn Voysey 4, Lucy Willetts 11, Nicola Williams 2, Ly-Mee Yu 4, Peter J Cooper 1,5

1 School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
2 Centre for Statistics in Medicine, University of Oxford, Oxford, UK
3 Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
4 Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
5 Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
6 Institute of Child Health, University College London, London, UK
7 Department of Psychiatry, University of Oxford, Oxford, UK
8 School of Public Health, University of Witwatersrand, Witwatersrand, South Africa
9 Health Economics Research Centre, University of Oxford, Oxford, UK
10 National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK
11 Berkshire Healthcare NHS Foundation Trust, Reading, UK
* Corresponding author Email: c.creswell@reading.ac.uk

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The full text of this issue is available as a PDF document from the Toolkit section on this page.

The full text of this issue is available as a PDF document from the Toolkit section on this page.

Abstract

BACKGROUND

Cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder.

OBJECTIVES

This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated.

DESIGN

Participants were randomised to receive (i) child cognitive-behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBTâ +â maternal cognitive-behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother-child interactions (MCIs) (CCBTâ +â MCI).

SETTING

A NHS university clinic in Berkshire, UK.

PARTICIPANTS

Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder.

INTERVENTIONS

All families received eight sessions of individual CCBT. Mothers in the CCBTâ +â MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact.

MAIN OUTCOME MEASURES

Primary clinical outcomes were the child's primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost-utility analysis framework with associated uncertainty.

RESULTS

MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBTâ +â MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBTâ +â MCBT nor CCBTâ +â MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, pâ =â 0.29; adjusted RR CCBTâ +â MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, pâ =â 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, pâ =â 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, pâ =â 0.13). CCBTâ +â MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBTâ +â MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%.

CONCLUSIONS

Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19762288.

FUNDING

This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

Abstract

BACKGROUND

Cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder.

OBJECTIVES

This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated.

DESIGN

Participants were randomised to receive (i) child cognitive-behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBTâ +â maternal cognitive-behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother-child interactions (MCIs) (CCBTâ +â MCI).

SETTING

A NHS university clinic in Berkshire, UK.

PARTICIPANTS

Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder.

INTERVENTIONS

All families received eight sessions of individual CCBT. Mothers in the CCBTâ +â MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact.

MAIN OUTCOME MEASURES

Primary clinical outcomes were the child's primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost-utility analysis framework with associated uncertainty.

RESULTS

MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBTâ +â MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBTâ +â MCBT nor CCBTâ +â MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, pâ =â 0.29; adjusted RR CCBTâ +â MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, pâ =â 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, pâ =â 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, pâ =â 0.13). CCBTâ +â MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBTâ +â MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%.

CONCLUSIONS

Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19762288.

FUNDING

This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

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