Skip to main content

Online CBT in the Treatment of Child and Adolescent Anxiety Disorders: Issues in the Development of BRAVE–ONLINE and Two Case Illustrations

  • Susan H. Spence (a1), Caroline L. Donovan (a1), Sonja March (a2), Amanda Gamble (a3), Renee Anderson (a2), Samantha Prosser (a2), Amy Kercher (a3) and Justin Kenardy (a2)...

This paper describes the rationale for and development of an online cognitive-behavioural treatment for child and adolescent anxiety (BRAVE–ONLINE). It highlights the challenges involved in adapting a clinic-based intervention for delivery using the internet, with separate sessions for parents and their children (or adolescents). We outline strategies to ensure that young people remain engaged in online therapy, and describe techniques designed to optimize the alliance between clients and the online therapist. Two case studies are presented that illustrate the practical and technical aspects of implementing the intervention, and demonstrate the feasibility of achieving successful outcomes using online delivery of CBT for child and adolescent anxiety. However, firm conclusions regarding the efficacy of this approach cannot be drawn until the results of randomized controlled trials are available. The paper identifies directions for future research.

Corresponding author
Reprint requests to Susan Spence, Griffith University, Gold Coast Campus, Queensland 4222, Australia. E-mail:
Hide All
Achenbach, T. M. and Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms and Profiles. Burlington, VT: University of Vermont, Research Centre for Children, Youth and Families.
Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall.
Barrett, P. M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 27, 459468.
Booth, M. L., Bernard, D., Quine, S., Kang, M. S., Usherwood, T., Alperstein, G. and Bennett, D. L. (2004). Access to health care among Australian adolescents: young people's perspectives and their sociodemographic distribution. Journal of Adolescent Health, 34, 97103.
Borkovec, T. D. and Nau, S. D. (1972). Credibility of analogue therapy rationales. Journal of Behavior Therapy and Experimental Psychiatry, 3, 257260.
Cornwall, E., Spence, S. H. and Schotte, D. (1996). The effectiveness of emotive imagery in the treatment of darkness phobia in children. Behaviour Change, 13, 223229.
Dadds, M. R., Davey, G. C. L. and Field, A. P. (2001). Developmental aspects of conditioning processes in anxiety disorders. In Vasey, M. W. and Dadds, M. R. (Eds.), The Developmental Psychopathology of Anxiety. Oxford: Oxford University Press.
Dewis, L. M., Kirkby, K. C., Martin, F., Daniels, B. A., Gilroy, L. J. and Menzies, R. G. (2001). Computer-aided vicarious exposure versus live graded exposure for spider phobia in children. Journal of Behavior Therapy and Experimental Psychiatry, 32, 1727.
Essau, C. A., Conradt, J. and Petermann, F. (2000). Frequency, comorbidity, and psychosocial impairment of anxiety disorders in German adolescents. Journal of Anxiety Disorders, 14, 263279.
Fung, D. S. S., Manassis, K., Kenny, A. and Fiksenbaum, L. (2002). Web-based CBT for selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 112113.
Griffiths, K. M. and Christensen, H. (2006). Review of randomised controlled trials of internet interventions for mental disorders and related conditions. Clinical Psychologist, 10, 1629.
Howgego, I. M., Yellowlees, P., Owen, C., Meldrum, L. and Dark, F. (2003). The therapeutic alliance: the key to effective patient outcome? A descriptive review of the evidence in community mental health case management. Australian and New Zealand Journal of Psychiatry, 37, 169183.
Hudson, J. L. (2005). Efficacy of cognitive-behavioural therapy for children and adolescents with anxiety disorders. Behaviour Change, 22, 5570.
Iverson, G. L. (2001). Interpreting change on the WAIS-III/WMS-III in clinical samples. Archives of Clinical Neuropsychology, 16, 183191.
Jacobson, N. S. and Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 1219.
Kaltenthaler, E., Brazier, J., De Nigris, E., Tumur, I., Ferriter, M., Berverley, C., Parry, G., Rooney, G. and Sutcliffe, P. (2006). Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technology Assessment, 10, 1186.
Kenardy, J. A. and Adams, C. (1993). Computers in cognitive-behaviour therapy. Australian Psychologist, 28, 189194.
Kenardy, J. A., Dow, M. G. T., Johnston, D. W., Newman, M. G., Thomson, A. and Taylor, C. B. (2003). A comparison of delivery methods of cognitive-behavioral therapy for panic disorder: an international multicenter trial. Journal of Consulting and Clinical Psychology, 71, 10681075.
Kendall, P. C. (1994). Treating anxiety disorders in children: results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100110.
Lyneham, H. J. and Rapee, R. M. (2005). Agreement between telephone and in-person delivery of a structured interview for anxiety disorders in children. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 274282.
Martin, D. J., Garske, J. P. and Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438450.
Muris, P., Schmidt, H. and Merckelbach, H. (2000). Correlations among two self-report questionnaires for measuring DSM-defined anxiety disorder symptoms in children: the Screen for Child Anxiety Related Emotional Disorders and the Spence Children's Anxiety Scale. Personality and Individual Differences, 28, 333346.
Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H. and Waters, A. (2004). A parent-report measure of children's anxiety: Psychometric properties and comparison with child-report in a clinic and normal sample. Behaviour Research and Therapy, 42, 813839.
Nelissen, I., Muris, P. and Merckelbach, H. (1995). Computerized exposure and in vivo exposure treatments of spider fear in children: two case reports. Journal of Behavior Therapy and Experimental Psychiatry, 26, 153156.
Ollendick, T. H., King, N. J. and Muris, P. (2002). Fears and phobias in children: phenomenology, epidemiology, and aetiology. Child and Adolescent Mental Health, 7, 98106.
Rapee, R. M. and Spence, S. H. (2004). The etiology of social phobia: empirical evidence and an initial model. Clinical Psychology Review. Special Social Phobia and Social Anxiety, 24, 737767.
Rapee, R. M., Wignall, A., Hudson, J. L. and Schniering, C. A. (2000). Treating Anxious Children and Adolescents: an evidence-based approach. Oakland, CA: Harbinger Publications.
Schaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, D., Bird, H. and Aluwahlia, S. (1983). A Children's Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 12281231.
Silverman, W. K. (1994). Structured diagnostic interviews. In Ollendick, T. H. and King, N. J. (Eds.), International Handbook of Phobic and Anxiety Disorders in Children and Adolescents. issues in clinical child psychology (pp. 293315). New York: Plenum Press.
Silverman, W. K. and Albano, A. M. (1996). Anxiety Disorders Interview schedule for DSM-IV – Child Version: Parent Interview Schedule. San Antonio: The Psychological Corporation – Harcourt, Brace and Company.
Silverman, W. K. and Treffers, P. D. A. (2001). Anxiety Disorders in Children and Adolescents: research, assessment and intervention. New York: Cambridge University Press.
Spek, V., Cuijpers, P., NyklÃcek, I., Riper, H., Keyzer, J. and Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine, 37, 319328.
Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545566.
Spence, S. H., Barrett, P. M. and Turner, C. M. (2003). Psychometric properties of the Spence children's anxiety scale with young adolescents. Journal of Anxiety Disorders, 17, 605625.
Spence, S. H., Donovan, C. and Brechman-Toussaint, M. (2000). The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitive-behavioural intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41, 713726.
Spence, S. H., Holmes, J. M., Donovan, C. L. and Kenardy, J. (2006). BRAVE for Teenagers – ONLINE: an internet based program for adolescents with anxiety. Brisbane, Australia: School of Psychology, University of Queensland.
Spence, S. H., Holmes, J. M., March, S. and Lipp, O. V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74, 614621.
Spence, S. H., March, S. and Holmes, J. M. (2005). BRAVE for Children – ONLINE: an internet based program for children with anxiety. Brisbane, Australia: School of Psychology, University of Queensland.
Tracey, T. J. and Kokotovic, A. M. (1989). Factor structure of the Working Alliance Inventory. Psychological Assessment, 1, 207210.
Vasey, M. W. and Dadds, M. R. (2001). The Developmental Psychopathology of Anxiety. London: Oxford University Press.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Behavioural and Cognitive Psychotherapy
  • ISSN: 1352-4658
  • EISSN: 1469-1833
  • URL: /core/journals/behavioural-and-cognitive-psychotherapy
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 23
Total number of PDF views: 220 *
Loading metrics...

Abstract views

Total abstract views: 1088 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd March 2018. This data will be updated every 24 hours.