Susan H Spence, B.Sc. (Hons), MBA, PhD (Clinical Psychology) is an Emeritus Professor in the School of Psychology and Australian Institute for Suicide Research and Prevention at Griffith University, Queensland, Australia. Her research in clinical psychology focuses on the causes, assessment, prevention and treatment of anxiety and depression in young people. Susan, along with Dr Sonja March (University of Southern QLD) and Dr Caroline Donovan (Griffith University), was one of the developers of BRAVE-ONLINE, an evidence-based, internet-delivered treatment program for anxiety in children and adolescents.
What is BRAVE-ONLINE?
BRAVE-ONLINE is a ten-week, online program for the treatment and early intervention of anxiety problems in children and teenagers. It consists of ten sessions that are completed by the child, and five or six sessions for their parents, with separate programs for children versus adolescents.
The program is designed for the four most common types of anxiety in young people: social anxiety, generalized anxiety, separation anxiety and specific phobias. The treatment incorporates cognitive behavioural anxiety management strategies, including psycho-education; relaxation training; recognition of the body signs of anxiety; cognitive strategies of coping self-talk and cognitive restructuring; graded exposure; problem solving; and self-reinforcement. Parents also learn these strategies in dedicated parent sessions, in addition to psycho-education about youth anxiety and training in contingency management strategies. Parent sessions are designed to empower the parent to help their child or adolescent implement strategies and effectively manage situations in which their child becomes anxious.
The sessions are engaging and interactive, whilst keeping in mind the developmental age of the intended audience. During the development of the program, feedback was obtained from children and adolescents and their parents to ensure the usability and acceptability of the program. Advice was also sought to ensure that the site would be socially inclusive across a range of ethnic backgrounds. Eye-catching graphics, sounds, games and quizzes are used through the sessions to maintain the young person’s level of interest. Sessions include explanations of CBT techniques, real-life examples to demonstrate how each skill can be implemented, opportunities for the participant to apply the technique to their own anxiety-provoking situations and homework exercises that are reviewed at the beginning each new session.
Is BRAVE-ONLINE effective?
Three randomised control trials support the effectiveness of BRAVE-ONLINE when offered in combination with very brief therapist support via email. The program has shown to result in significantly greater reductions in anxiety than a waiting list control and effects equivalent to face-to-face delivery of the program in the clinic (March, Spence, & Donovan, 2009; Spence et al., 2011; Spence, Holmes, March, & Lipp, 2006). Unfortunately, there are just not enough mental health professionals to meet the level of demand for treatment of youth anxiety. In response to this problem, we developed a self-help version of BRAVE-ONLINE.
How can health and community professionals use BRAVE with their clients?
BRAVE-ONLINE can be completed either by children and families at home, on a self-help basis, or it can be used in combination with clinic therapy. We find it is helpful if there is a professional to provide support, encouragement and brief advice to children and families while they do the program, to keep them motivated to complete the sessions. The detailed CBT instructions are built into the program which allows for support and advice to be provided by professionals who do not have specialist skills in this area. In school settings, the program can be used with small groups of anxious young people under the supervision of a health or community professional.
What advice do you have for health and community professionals working with children with anxiety and their families?
It is important that anxious children are detected as early as possible before the anxiety becomes entrenched and so that they can be receive the treatment they need. Often anxious children go undetected because they can be shy and compliant at school and in social settings. There is often an assumption that anxiety is just a phase and that it will go away on its own over time. Teachers, in particular, need to be on the lookout for children who are suffering silently.
Parents have an important role to play in therapy programs in order to learn techniques to help their child to overcome anxiety. However, children and adolescents can also gain benefit by completing the BRAVE-ONLINE program themselves in small groups with support and supervision.
March, S., Spence, S. H., & Donovan, C. L. (2009). The efficacy of an Internet-based cognitive-behavioral therapy intervention for child anxiety disorders. Journal of Pediatric Psychology, 34(5), 474-487.
Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., & Kenardy, J. (2011). A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79(5), 629-642.
Spence, S. H., Holmes, J. M., March, S., & 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(3), 614-621.