An Investigation of Engagement in Parent-Administered, Internet-Delivered Cognitive Behaviour Therapy for Childhood Anxiety: Intervention Usage and Subjective Experience
Abstract
Childhood anxiety is the most prevalent mental health concern facing Canadian children
but often goes untreated. Parent-administered, Internet-delivered cognitive behaviour
therapy (ICBT) has been suggested as an approach to improve treatment access. For this
approach to be effective, however, it is important to ensure that parents will use and
remain engaged with the treatment intervention. ICBT researchers frequently include
measures of engagement in efficacy studies, but the measures tend to be uni-dimensional
and inconsistent across studies. Perski, Blandford, West, and Michie (2017) developed a
conceptual model of engagement, designed to address limitations in the literature by
capturing two broad dimensions of engagement: objective (i.e., intervention usage) and
subjective (i.e., attention and interest). The aim of the present study was to use the Perski
model to examine engagement within parent-administered ICBT. Ninety-one parents of
children with anxiety participated in the nine-week, therapist-guided, parent-administered
ICBT program, Anxiety treatment for Children through online Education (ACE).
Measures of population characteristics (e.g., demographics; child and parent mental
health; parent beliefs) and intervention features (e.g., credibility; satisfaction; working
alliance) were administered throughout treatment. Measures of objective engagement
(i.e., number of logins per week; number of messages sent by participant to their coach)
and subjective engagement (i.e., the Digital Behaviour Change Interventions Engagement
Scale) were collected at post-treatment. Forty-seven parents completed the entire
intervention, while 44 dropped out. Analyses revealed that 20.3% of parents who dropped
out did so during the first lesson, while the remaining parents dropped out at varied
timepoints. There were no differences in population characteristics between families who
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dropped out early in the program and those who dropped out later. Higher pre-treatment
child anxiety symptoms, lower pre-treatment parent mental health symptoms, and higher
levels of parent education were associated with a greater likelihood of program
completion. Primary analyses focused on engagement among parents who completed the
entire intervention. Findings suggested that more negative parent beliefs about child
anxiety predicted higher objective engagement but were also associated with higher child
anxiety scores across treatment. Higher credibility and content satisfaction were
associated with higher subjective engagement. The working alliance was the only factor
associated with both objective and subjective engagement (i.e., a stronger working
alliance predicted higher engagement). Importantly, child anxiety symptoms significantly
improved from pre- to post-treatment. Neither objective nor subjective engagement was
associated with treatment outcome, although this was likely due to methodological issues
with the measurement of engagement. Findings have important implications for the
development of parent-administered ICBT, highlighting a need to examine the working
alliance, parent beliefs about anxiety, and content satisfaction as potential avenues for
enhancing engagement and outcome. Findings also have implications for the systematic
investigation of engagement in low-intensity interventions; most notably, findings
underscore the importance of including multi-dimensional measures of engagement.
Ultimately, the present study serves as a valuable step forward in understanding and
maximizing engagement in low-intensity interventions, which can lead to the refinement
of more accessible treatment options for children struggling with anxiety.