Feasibility study of the e-learning version of the “Journey of the Brave”: A universal anxiety prevention program based on cognitive behavioral therapy

Feasibility study of the e-learning version of the “Journey of the Brave”: A universal anxiety prevention program based on cognitive behavioral therapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility study of the e-learning version of the “Journey of the Brave”: A universal anxiety prevention program based on cognitive behavioral therapy Shoichi Ohashi, Yuko Urao, Kazumasa Fujiwara, Takako Koshiba, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4638877/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted 9 You are reading this latest preprint version Abstract Background School-based cognitive behavioral therapy (CBT) programs could contribute toward preventing anxiety disorders in children. However, setting aside class time for such programs is difficult. Internet-based CBT (I-CBT) is an efficient way to provide CBT. However, studies on I-CBT for anxiety prevention are still scarce, including I-CBT for school-based universal prevention programs. Therefore, we developed an e-learning version of a school-based anxiety prevention CBT program “Journey of the Brave,” which was effective in Japan, to make it more flexible and accessible. This study evaluated its feasibility. Methods We conducted a single-arm study with 44 parents and children. Children aged 10–12 took the e-learning program at home. Parents and children responded to a questionnaire three times: before the learning (Pre), after the learning (Post), and three months later (FU: Follow-up). Feasibility was comprehensively evaluated through dropout rates, satisfaction and learning records, and changes in scores on psychological scales. Results Of the 44 children, 42 started the e-learning, and 32 continued it (dropout rate of 23.8%). Furthermore, 83.9% of children and 96.8% of parents responded “agree” or “somewhat agree” regarding overall satisfaction. The parent-rated the Spence Children's Anxiety Scale ( SCAS) (SCAS-P) showed a significant decrease between Pre and FU ( p = 0.014, 95%CI= (-9.22, -0.84)); however, the child-rated SCAS (SCAS-C) did not ( p = 0.08). The Emotion‑Regulation Skills Questionnaire ( ERSQ) also increased significantly between Pre and FU ( p = 0.045, 95%CI= (0.18, 18.31)). Total Difficulties Score of the Strengths and Difficulties Questionnaire ( SDQ) decreased significantly from Pre to Post ( p = 0.025, 95%CI= (-3.62, -0.19)); however, it was not significantly different between Pre and FU ( p = 0.67). Conclusion The e-learning version showed low dropout rates and high satisfaction ratings from parents and children. Moreover, this study did not rule out the possibility that the program reduced children's anxiety and improved their emotional regulation skills. Therefore, its potential and feasibility were indicated. children’s anxiety universal prevention program internet-based cognitive behavioral therapy (I-CBT) e-learning gamification feasibility study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 1. Background Anxiety disorders are common psychiatric disorders that present in early childhood [ 1 ], with a lifetime prevalence of approximately 15–20% in children and adolescents [ 2 ]. Merikangas et al. reported that approximately 1 in 3 adolescents met the diagnostic criteria for an anxiety disorder [ 3 ]. Anxiety disorders in childhood predict the maintenance of anxiety and other psychiatric disorders in adolescence [ 4 ]. Furthermore, anxiety disorders in adolescence also increase the risk of anxiety and depression in adulthood [ 5 ] and predict other psychiatric disorders, such as alcoholism and chronic stress, and life situations, such as social maladjustment and low income [ 6 ]. Since anxiety disorders in children and adolescents rapidly increase between the ages of 10–19 years [ 7 ], childhood prevention and early intervention are necessary [ 8 ]. In Japan, anxiety problems are a factor contributing to the increasing trend of children not attending school. According to a survey conducted by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), approximately half (51.8%) the reasons for non-attendance were “apathy and anxiety,” with the proportion increasing each year [ 9 ]. Recent concerns regarding mental health problems among children have been linked to COVID-19 [ 10 , 11 ], which has led to increasing interest in addressing anxiety in schools. Meta-analyses have repeatedly confirmed the effectiveness of anxiety prevention approaches implemented in schools, which are also practical [ 12 , 13 ]. Prevention approaches include the universal approach, which is not targeted, and approach for at-risk or symptomatic individuals (Institute of Medicine (US) Committee on Prevention of Mental Disorders, 1994). Since the universal approach does not create labeling and stigmatization [ 14 ], its adoption is appropriate to implement anxiety prevention programs in schools. Urao et al. noted that child anxiety prevention programs developed in certain countries did not always demonstrate the expected effects in other countries. Subsequently, they developed a school-based universal anxiety prevention program called “Journey of the Brave,” based on cognitive behavioral therapy (CBT), tailored to the Japanese cultural and social context [ 15 ]. The program was conducted by teachers who received six hours of training via a facilitator’s manual [ 16 ]. However, it was structured around the work that children did on their own, and the learning content was designed to be understood by teacher’s lectures and workbook reading. Previous studies suggested that school-based CBT programs were not as effective when delivered by teachers compared to by medical professionals [ 17 , 18 ]. However, the “Journey of the Brave” program demonstrated effectiveness in reducing anxiety among 10–12-year-olds even when presented by teachers [ 16 , 19 ]. However, in Japan, finding sufficient time to provide classes not stipulated by the MEXT was difficult. Furthermore, it placed a heavy burden on teachers in addition to in-class preparation. In addition, many schools suspended the program in 2021 owing to the COVID-19 pandemic that made it difficult to conduct face-to-face classes. Therefore, we considered ways to reduce the burden on schoolteachers and provide prevention programs flexibly. Internet-delivered CBT (I-CBT) is an effective treatment for psychiatric disorders in children [ 20 ]. I-CBT has received increasing attention owing to raised concerns regarding face-to-face treatment during the COVID-19 pandemic [ 21 ]. Although not clearly defined, I-CBT can be broadly classified as guided or unguided and is a self-help format program with documents, audio, and video [ 22 ]. I-CBT for anxiety disorders was more cost-effective than regular CBT treatment [ 23 ]. Guided I-CBT is comparable to face-to-face treatment in terms of session completion rates [ 24 ], although it required approximately one-eighth of the therapist's time [ 25 ]. Its effectiveness was also comparable to face-to-face sessions for children with anxiety disorders [ 26 , 27 ]. However, despite meaningful reports on the treatment, studies on I-CBT programs for prevention are scarce and warrant future research [ 28 ]. Thus, we saw the potential of an e-learning version of the “Journey of the Brave” program. Since it was an individual work-based program with little interaction with teachers or classmates, it was relatively easy to convert written content into screen images. In addition, the Japanese government promoted a project called the GIGA (Global and Innovation Gateway for All) School Initiative [ 29 ] in response to the COVID-19 pandemic. Hence, most elementary and junior high schools now have one computer per student. Hence, if we can offer the program in a self-learning format through I-CBT, students can learn at their own pace at home or wherever they like, with teachers guiding them when necessary. If sufficient class time is unavailable, the program could be implemented flexibly, such as during self-study time, which could reduce the burden on teachers. A recent study on the “Journey of the Brave” reported reduced anxiety scores, even when the program was divided into short classroom activities of 20 minutes. This demonstrated that the program was effective without necessarily using 45–50 minutes of classroom time at once [ 30 ]. Hence, we developed an e-learning version that allowed students to view class videos and answer work and tests over the Internet to make it more flexible and lower the burden on teachers owing to school implementation. "Journey of the Brave" is a school-based universal prevention program, and we envision an e-learning version also being offered in schools. However, simultaneously, fundamental verification is required to ensure that the e-learning version works correctly and that children can operate and understand it themselves as self-help material. Therefore, we aimed to evaluate the feasibility of the e-learning version at home rather than at school. 2. Methods 2.1. Aim and Setting This study evaluated the feasibility of a newly developed e-learning version of “Journey of the Brave” via a single-arm intervention trial with no control group. Both parents and children participated. The intervention was provided only to the children; however, both completed a questionnaire to evaluate its feasibility. The study was approved by the Ethics Review Committee of Chiba University School of Medicine. 2.2. Participants Participants were fifth- and sixth-grade students (aged 10–12 years) enrolled in regular classes. Furthermore, the same parent answered all the questionnaires. Since this was a preventive intervention program, we excluded children who were not attending school, enrolled in special-needs classes, diagnosed with developmental disabilities or psychiatric disorders, or attended psychiatric hospitals. We recruited participants through the official “Journey of the Brave” website and flyers distributed to approximately 1,500 children through several schools in the Chiba and Ibaraki prefectures from August to September 2022. Applications and informed consent forms were available on the web. Furthermore, participants could apply only if they had read and agreed to the written instructions. A plain language children's assent document was also available on the web to ensure that both the parents and children were willing to participate. 2.3. Intervention We developed an e-learning version to replicate the classroom experience on a computer. Learning modules, called stages, comprised eight learning stages and a review stage, similar to the original (Table 1 ). Primarily, participants watched the videos and answered the questions in a workbook, with between one and five works per stage. Each stage included one core work and check tests that participants answered on the e-learning system so that the administrator could review the content. Furthermore, homework was provided for each stage. We asked participants to allow at least one week between two stages to work on homework, with a maximum study period of six months. However, we left the actual learning cycle up to them, which allowed for flexibility. In addition, although the e-learning system was designed so that participants could not proceed to the next stage unless they had completed the previous video or work; for homework assignments, participants were allowed to proceed even if they had not submitted the work. The e-learning version, which required children to learn at their own pace and on their initiative, had various features to encourage learning (Fig. 1 ). We employed a system whereby participants earned points upon completion of a stage and submitting the homework results. Participants earned new items and characters as they accumulated points and progressed through the levels. Participants could choose and display any characters acquired on the learning screen. We also sent a reminder message with content after they had completed stages 1, 3, and 8 to encourage continued learning. We also implemented a feature that allowed participants to ask questions when unsure. These features were developed based on previous research, which demonstrated that rewards, personalization, reminders, and a supportive environment from others in I-CBT programs increased children's adherence [ 31 ]. Table 1 Contents by session Session Content 1 Understanding of four basic feelings 2 Monitoring feelings of anxiety and setting goals 3 Body reactions and relaxation 4 Anxiety level stages and stair step exposure 5 Anxiety cognition model 6 Identify cognitive distortions and coping with rumination 7 Cognitive restructuring when anxious 8 Assertiveness skills to reduce social stress 9 Review and summary 2.4. Procedure We sent an e-learning account for each participating parent and child to the parent's e-mail address. When the children first logged onto the website to begin learning, we reaffirmed their assent by displaying an assent document that stated that they wished to learn on their own initiative and could withdraw at any time. Parents and children responded to a questionnaire that comprised the evaluation indicators three times: before the learning began (Pre), at the end (Post), and three months later (FU: Follow-up). We designed the questionnaire to be integrated into the learning process so that it would be clear when to respond. The first video was available after children had responded to the pre-study questionnaire. Conversely, we sent an e-mail to the parents when they had to respond to the questionnaire based on their children's learning progress. In addition, we set up the system so that parents could not only respond to the questionnaire, but also view the class videos so that they could see what their children would be learning. During the study period, we checked on the children's progress approximately once a week. If there was no access for > 10 days, we sent an e-mail to the parents to confirm that they were still interested in participating. 2.5. Measurements The primary outcome was the dropout rate. We evaluated whether children completed the program even in its e-learning version. We also comprehensively evaluated its feasibility, which included the results of satisfaction questionnaires rated on a 4-point scale and learning scores as secondary outcomes. In addition, psychological scale scores were also used as secondary outcomes. We cannot discuss the effect of the intervention as this was a single-arm trial. However, we considered how anxiety and other scores changed over the study period as an essential feasibility component. 2.5.1. Spence Children's Anxiety Scale (SCAS) The SCAS assessed the severity of anxiety disorders in children [ 32 ], and the validity of the Japanese version has been demonstrated [ 33 ]. Since parental ratings were also helpful in assessing children's anxiety [ 34 ], we used both, the scales that children answered themselves (SCAS-C) and those that parents answered regarding their children (SCAS-P) [ 35 ]. Previous studies confirmed that classes with “Journey of the Brave” reduced the mean scores on the SCAS-C [ 16 , 19 , 30 ]. The SCAS-P was also used in studies during the program’s early development and found significant reductions [ 15 ]. 2.5.2 EmotionRegulation Skills Questionnaire (ERSQ) The ERSQ is the English version [ 36 ] of the Selbsteinschätzung Emotionaler Kompetenzen (SEK-27) [ 37 ]. The Japanese version demonstrated reliability and validity in a previous study [ 38 ]. Hence, we used this scale as a secondary outcome, with supplementary explanations for difficult words for elementary school children to observe the multi-dimensional changes before and after e-learning. 2.5.3 Strengths and Difficulties Questionnaire (SDQ) The SDQ comprised 25 items on five subscales that assessed children's emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior [ 39 ]. Reliability and validity of the Japanese version, wherein parents responded regarding their children's anxiety, have been demonstrated [ 40 ]. The Total Difficulties Score (TDS), sum of the scores without the prosocial behavior subscale, had a maximum score of 40. A score of > 13 and > 16 were considered “some need” and “high need,” respectively. We used the TDS to observe the multi-dimensional changes in the child as perceived by the parents before and after the e-learning program. 2.6. Analysis The dropout rate was calculated as the percentage of children who started the program and withdrew during the 6-month study period. We did not consider those who did not complete the program during the study period as they could continue it. We confirmed their intention to continue each time through the parents if there was no access for < 10 days. We obtained descriptive statistics from participants regarding satisfaction and from various learning records (e.g., checking test scores and number of homework assignments submitted). We analyzed continuous variables recording changes in psychological scale scores from Pre to FU via a repeated measures analysis of variance (ANOVA). Since the study purpose was to evaluate feasibility, it was also valuable to infer the type of children it would be more effective for and obtain findings that will contribute to future improvements. Therefore, we also compared two groups divided according to differences in psychological scale scores at the Pre time point. IBM SPSS Statistics version 28 was used for analysis. 3. Results 3.1. Dropout Rate Of the 46 parents and their children who agreed to participate, we excluded two pairs as one child was younger than the target grades and another withdrew before the Pre-questionnaire. Therefore, 44 pairs participated (Fig. 2 , Table 2 ). Of these, four were single-mother families. Majority (19 (43.2%)) had a household income of > 9 million yen ( $ 60,000). Furthermore, 34 (77.3%) fathers and 31 (70.5%) mothers had completed university or graduate school. Parents’ average age was 44.4 years (38–52 years), of whom only two (4.5%) were fathers and 42 (95.5%) were mothers. Since two children responded to the Pre-questionnaire yet withdrew without starting the e-learning program, 42 children, 29 (13 boys and 16 girls) and 13 (six boys and seven girls) in the fifth and sixth grades, respectively, actually started the study. Of these, 9 dropped out during their learning while one lost contact (dropout rate of 23.8%). Of the remaining 32 children, 28 completed the entire program, and the remaining four continued learning throughout the period and completed at least five or more stages (one completed five stages, one completed seven stages, and two completed eight stages). All 32 pairs also completed the Post- and FU questionnaires. Table 2 Participants’ demographic data Participants (n = 44) Children's Information Sex Female 25 (56.8%) Male 19 (43.2%) Grade 5th 30 (68.2%) 6th 14 (31.8%) Reports from Parents Respondent Father 2 (4.5%) Mother 42 (95.5%) Average Age of Respondents 44.4 (38–52) Family Composition Parents and child 40 (90.9%) Fatherless family 4 (9.1%) Household Incomes 9 million yen 19 (43.2%) Father’s Final Education Junior high school 1 (2.3%) High school 4 (9.1%) Vocational schools, junior colleges, etc. 5 (11.4%) University or graduate school 34 (77.3%) Mother’s Final Education Junior high school 0 (0%) High school 6 (13.6%) Vocational schools, junior colleges, etc. 7 (15.9%) University or graduate school 31 (70.5%) 3.2. Satisfaction and Learning Records Figure 3 presents the details of the Post and FU questionnaire responses regarding satisfaction. In total, 27 children (27/32, 84.4%) and 30 parents (30/31, 96.8%), and 26 children (26/31, 83.9%) and 30 parents (30/31, 96.8%) answered “agree” or “somewhat agree” to the overall satisfaction question in Post and in FU, respectively. The 28 children who completed all stages took an average of 13.6 weeks for completion (measured from Stage 1 completion owing to different lengths of time between questionnaire responses and starting Stage 1). The average score of the 29 children who answered the comprehension test (correct/incorrect questions) on all the content learned, which was provided in the last stage (Stage 9), was 14.6 out of 16 points (11–16, SD = 1.21). Conversely, the average number of times they submitted their homework was 8.6 times (of 15). Furthermore, there was a wide variation in their commitment to homework from 0–15 times (SD = 6.28). 3.3. Changes in Psychological scales Table 3 presents the mean scores and standard deviations for each psychological scale from Pre to FU and results from repeated measures ANOVA. The 32 pairs who continued the program were analyzed. Data from children with missing items or responses were excluded. The mean SCAS-C score decreased by 4.37 points from Pre to FU (from 25.63 to 21.26); however, there was no significant difference between the three time points ( p = 0.08) (Fig. 4 ). Conversely, the mean SCAS-P score decreased by 5.03 points (from 17.69 to 12.66), which indicated a significant difference between Pre and FU ( p = 0.014, 95%CI= (-9.22, -0.84)) and Post and FU ( p = 0.004, 95%CI= (-7.50, -1.25)), respectively (Fig. 5 ). The mean ERSQ score increased by 9.24 points (63.45 to 72.69), which indicated a significant difference between Pre and FU ( p = 0.045, 95%CI= (0.18,18.31)) (Fig. 6 ). The mean SDQ-TDS score rated by parents decreased by 1.9 points from Pre to Post (from 11.59 to 9.69 points), which indicated a significant difference ( p = 0.025, 95%CI= (-3.62, -0.19)), and increased by 0.9 points from Post to FU. Thus, Pre and FU had no significant difference ( p = 0.67) (Fig. 7 ). Table 3 Changes in the mean and standard deviation of each psychological scale. Scales Pre, Mean (SD) Post, Mean (SD) FU, Mean (SD) F P SCAS-C (n = 27) 25.63 (12.26) 25.15 (14.50) 21.26 (13.06) 2.65 0.080 SCAS-P (n = 32) 17.69 (10.25) 17.03 (7.95) 12.66 (7.52) 7.18** 0.002 ERSQ (n = 29) 63.45 (20.58) 68.38 (20.51) 72.69 (18.50) 3.39* 0.041 SDQ-TDS (n = 32) 11.59 (5.80) 9.69 (5.87) 10.59 (5.40) 3.74* 0.029 Comparison of the scores Mean difference (SE) P 95%CI of Mean difference Lower limit Upper limit SCAS-P Pre Post 0.66 (1.41) 1.000 -2.91 4.22 (n = 32) FU 5.03* (1.66) 0.014 0.84 9.22 Post FU 4.38** (1.24) 0.004 1.25 7.50 ERSQ Pre Post -4.93 (4.00) 0.685 -15.12 5.26 (n = 29) FU -9.24* (3.56) 0.04 -18.31 -0.18 Post FU -4.31 (3.03) 0.50 -12.02 3.40 SDQ-TDS Pre Post 1.91* (0.68) 0.025 0.19 3.62 (n = 32) FU 1.00 (0.80) 0.665 -1.03 3.03 Post FU -0.91 (0.60) 0.419 -2.42 0.61 SCAS-C/P, Spence Children’s Anxiety Scale Child/Parent version; ERSQ, EmotionRegulation Skills Questionnaire; SDQ-TDS, Strengths and Difficulties Questionnaire Total Difficulties Score. 3.4. Subgroup Analysis by Differences in Pre-intervention Scores Previous research found that the high group (top 10% of pre-intervention SCAS-C scores) showed a significant decrease in scores compared to the low group [ 16 ]. In this study, four children (9.1%) with SCAS-C scores of 45 or higher at Pre were considered a high group. However, two children and one child dropped out before the learning began and at Stage 1, respectively. Hence, subgroup analysis between high and low SCAS-C scores could not be performed. Therefore, we created a subgroup based on the SDQ-TDS at the Pre time point to evaluate differences in the SCAS-C and SCAS-P mean score changes at the three time points in each group (Table 4 ). Interaction between score changes and group for the SCAS-C was insignificant for the high and low group with an SDQ-TDS score of > 13 and < 13, respectively ( p = 0.96) (Fig. 8 ). However, a significant interaction was observed between score changes and group for the SCAS-P (F = 3.73, p = 0.03) (Fig. 9 ). Table 4 Within-subject effects of the SCAS and SDQ-TDS. Sum of Squares df Mean Square F P Observed Power SCAS-C Time 264.68 2 132.34 2.18 0.124 0.43 Time × TDS 4.43 2 2.21 0.04 0.964 0.06 Error 3037.47 50 60.75 SCAS-P Time 572.84 2 286.42 9.35 < 0.001 0.97 Time × TDS 228.39 2 114.19 3.73 0.030 0.66 Error 1838.18 60 30.64 3.5. Evaluation of E-learning Features In addition to satisfaction, the questionnaire also enquired ratings of the various features on a scale from 1 to 10. Table 5 presents the average rating scores for each of the e-learning features. The reward and personalization features, which allowed users to obtain items and characters and choose which characters to display, respectively, received relatively high evaluations. Conversely, the homework feature, called “self-training,” received the lowest evaluation. Table 5 Evaluation of e-learning features Rating out of 10 Average score of children Average score of parents Earn points 7.7 7.7 Obtain items and characters 8.0 8.4 Choose characters by themselves 8.0 8.3 Can do “self-training” 6.6 6.7 Receive reminder messages 7.3 7.5 Ask questions 8.2 7.2 4. Discussion 4.1 Feasibility We developed and evaluated the feasibility of an e-learning version of the “Journey of the Brave” anxiety prevention program for children in Japan. The dropout rate was 23.8%. Of the participants, 76.2% and 66.7% completed at least five and all the stages, respectively. Furthermore, 83.9% of children and 96.8% of parents responded positively to the overall satisfaction level at FU. No other I-CBT study used an e-learning format where children with no apparent symptoms or problems took a universal anxiety prevention CBT program on an individual basis. Therefore, we cannot make comparisons. However, a study on university students with mild-to-moderate depression or anxiety symptoms (“ICare Prevent”) reported that 54.2% and 39.6% completed four or more and all seven sessions, respectively [ 41 ]. Furthermore, a meta-analysis of 64 trials that examined the effectiveness of I-CBT for patients with depression or anxiety disorders found a median adherence and satisfaction rate of 66% and 86%, respectively [ 25 ]. Compared to these studies, many parents and children viewed this program positively, despite the inclusion of participants who did not experience anxiety issues. Regarding changes in psychological scale scores, a non-significant decrease was observed in the mean score for the SCAS-C; however, a significant decrease was observed for the SCAS-P from Pre to FU. These results were similar to those of a previous study [ 15 ]. It was possible that an e-learning version could also significantly reduce the mean SCAS-C score if a larger sample was included, similar to the original program. We also observed a significant increase in the mean ERSQ scores from Pre to FU, which indicated that children's emotion regulation skills increased before and after the program's implementation. The e-learning program could have promoted children's emotion regulation skills. This was a novel finding. Emotion regulation skills could be a predictor of prevention effectiveness in anxiety prevention programs targeting non-clinical groups. Previous studies reported that emotion regulation was associated with the onset and maintenance of anxiety disorders [ 42 ]. These results supported the feasibility of the e-learning version based on its acceptability regarding low dropout rates and high satisfaction levels, as well as the expected effects of reduced anxiety and improved emotional regulation skills. The mean SDQ-TDS, which indicated difficulties stemming from children's emotional and behavioral problems, showed a significant decrease from Pre to Post. Conversely, the decrease was not maintained in FU. This indicated that the change was not sustained, at least regarding the child's specific problems observable from a parent's perspective. It was possible that since this program was essentially an anxiety prevention education program, its other problem-solving effects could have been limited. Hence, continuous verification is required to make a more accurate reference. Most parents and children in the high SCAS-C score group dropped out without learning or dropped out early. Hence, we could not conduct subgroup analyses with high and low anxiety scores. We hypothesized that the e-learning version would also have a more significant effect on children with high anxiety. However, the population most likely to show a significant effect may not have accepted e-learning. Early dropouts may have resulted from an accidental outcome due to the small sample size or that highly anxious children felt burdened by the individualized learning experience. Clarifying the reasons they dropped out before learning and improving the e-learning to be more acceptable may deliver its effect to the high score group. The e-learning version may also have a pronounced anxiety reduction effect when implemented in schools, as in previous studies. Subgroup analysis by SDQ-TDS showed that the group of children considered to have support needs decreased significantly in mean scores on parent-rated anxiety (SCAS-P) from Pre to FU. This suggests that children with more difficulties in their daily lives could benefit from the program. However, there was no significant difference in the SCAS-C change. Hence, further examination with a larger sample size is required to make a more accurate reference. 4.2. Feature Improvements These findings indicate that the design of a series of features based on rewards and personalization, such as earning points and level progression through learning, adding items and characters via progression, and selecting favorite characters to display, were highly rated. Conversely, the features for receiving messages were rated less highly. Children had to click several times to reach the dedicated message box to see the messages. In addition, a researcher had to manually send the messages as the system could not automatically send prepared messages owing to system limitations. We do not want teachers to be burdened with sending messages, especially when conducting e-learning in a school environment. Hence, ensuring that a message is automatically displayed when each stage is completed is a future requirement. We were also disappointed that the homework feature, an essential component, was not rated very highly and polarized the children into two groups: those who worked on very little and those who worked on almost everything. However, no previous study examined the extent to which children engaged in the homework associated with the program. These results suggest that considering ways to ensure that children wanted to continue doing homework could improve the quality of the program. 4.3. Limitation This study has several limitations. First, the sampling issue. The participants might have been quite different from the classroom population where the program would be implemented as they were parents and children who willingly took the program. Furthermore, although the largest number of participants were from families with household incomes exceeding 9 million yen, the average annual income of households with children in Japan was 7.85 million yen [ 43 ]. Although > 70% of both parents who participated had a university or graduate school education, only 37.6% of men and 22.7% of women in their 40s in Japan had a university or graduate school education [ 44 ]. Hence, children who participated were raised by parents with high incomes and educational backgrounds, which may have influenced the children's lifestyle and attitudes toward e-learning. Second, we cannot inherently address the contribution of e-learning to changes in scores on psychological scales, including the anxiety preventive effect, as this was a single-arm study with no control group. We cannot assert that the positive changes were caused by e-learning, although we found significant positive changes in the SCAS-P and in ERSQ scores between Pre and FU. Furthermore, the reliability and validity of the Japanese version of the ERSQ has yet to be confirmed among elementary school students. However, we found no reason to doubt the feasibility of the e-learning version as we detected no adverse changes in any psychological scales, such as an increase in the mean anxiety score after the intervention. 5. Conclusion The study evaluated the feasibility of a newly developed e-learning version of the “Journey of the Brave” CBT-based anxiety prevention program, with 44 parent-child pairs. The study observed low dropout rates and high satisfaction from parents and children. We confirmed a specific feasibility, as it did not show any results contrary to expectations regarding reducing anxiety or improving emotional regulation skills. Verifying whether the e-learning version can show preventive effects of anxiety on the originally intended target population via comparison with a control group in a school environment is necessary. Abbreviations CBT Cognitive behavioral therapy I-CBT Internet-based cognitive behavioral therapy SCAS Spence Children's Anxiety Scale ERSQ Emotion‑Regulation Skills Questionnaire SDQ Strengths and Difficulties Questionnaire MEXT Ministry of Education, Culture, Sports, Science and Technology ANOVA Analysis of variance. Declarations Ethics approval and consent to participate The protocol was approved by the Ethics Review Committee of Chiba University School of Medicine in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects as well as the Declaration of Helsinki. Informed consent forms were available on the web which were filled out by the parents. A plain language children's assent document was also available on the web to ensure that both the parents and children were willing to participate. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by JSPS KAKENHI Grant Number 21K10934 and Osaka University's “Developing Next-Generation Researchers who Devote Themselves to Challenging Research Projects,” which was selected for the “Support for Pioneering Research Initiated by the Next Generation” program by the Japan Science and Technology Agency. Authors' contributions SO contributed to all aspects of the study design, e-learning development, data collection, statistical analysis, and manuscript preparation. YU oversaw the study design and e-learning development and provided advice in manuscript preparation. KF made major contributions to the study design and statistical analysis. TK contributed to the study design. SI contributed to data collection and manuscript revision. ES reviewed the study design and the manuscript. All authors read and approved the final manuscript. Acknowledgments We thank the children and parents who participated. References Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev. 2006;26:817–33. https://doi.org/10.1016/j.cpr.2005.12.002 . Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009;32:483–524. https://doi.org/10.1016/j.psc.2009.06.002 . Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National comorbidity Survey Replication-adolescent supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980–9. https://doi.org/10.1016/j.jaac.2010.05.017 . 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Geneva: World Health Organization; 2004. https://iris.who.int/bitstream/handle/10665/43027/924159215X_eng.pdf . MEXT (Ministry of Education, Culture, Sports, Science, and Technology). Survey on student behavioral problems, truancy, and other student guidance issues; 2023. https://www.mext.go.jp/content/20231004-mxt_jidou01-100002753_1.pdf . de Oliveira JMD, Butini L, Pauletto P, Lehmkuhl KM, Stefani CM, Bolan M, et al. Mental health effects prevalence in children and adolescents during the COVID-19 pandemic: A systematic review. Worldviews Evid Based Nurs. 2022;19:130–7. https://doi.org/10.1111/wvn.12566 . Jones EAK, Mitra AK, Bhuiyan AR. Impact of COVID-19 on mental health in adolescents: A systematic review. Int J Environ Res Public Health. 2021;18:2470. https://doi.org/10.3390/ijerph18052470 . Werner-Seidler A, Spanos S, Calear AL, Perry Y, Torok M, O’Dea B, et al. School-based depression and anxiety prevention programs: An updated systematic review and meta-analysis. 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Child Adolesc Psychiatry Ment Health. 2021;15:21. https://doi.org/10.1186/s13034-021-00374-6 . Skryabina E, Morris J, Byrne D, Harkin N, Rook S, Stallard P. Child, teacher and parent perceptions of the FRIENDS classroom-based universal anxiety prevention programme: A qualitative study. School Ment Health. 2016;8:486–98. https://doi.org/10.1007/s12310-016-9187-y . Stallard P, Skryabina E, Taylor G, Phillips R, Daniels H, Anderson R, et al. Classroom-based cognitive behaviour therapy (FRIENDS): A cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES). Lancet Psychiatry. 2014;1:185–92. https://doi.org/10.1016/S2215-0366(14)70244-5 . Urao Y, Yoshida M, Koshiba T, Sato Y, Ishikawa SI, Shimizu E. Effectiveness of a cognitive behavioural therapy-based anxiety prevention programme at an elementary school in Japan: A quasi-experimental study. Child Adolesc Psychiatry Ment Health. 2018;12:33. https://doi.org/10.1186/s13034-018-0240-5 . Vigerland S, Lenhard F, Bonnert M, Lalouni M, Hedman E, Ahlen J, et al. Internet-delivered cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clin Psychol Rev. 2016;50:1–10. https://doi.org/10.1016/j.cpr.2016.09.005 . Shirotsuki K, Sugaya N, Nakao M. Descriptive review of internet-based cognitive behavior therapy on anxiety-related problems in children under the circumstances of COVID-19. Biopsychosoc Med. 2022;16:3. https://doi.org/10.1186/s13030-021-00233-y . Kobayashi K, Yamada T, Fujii Y. A Prospective Study of Cognitive Behavioral Therapy via the Internet or Using Computer. Meisei Univ Psychol Res Minutes. 2019;37:25–32. Ophuis RH, Lokkerbol J, Heemskerk SCM, van Balkom AJLM, Hiligsmann M, Evers SMAA. Cost-effectiveness of interventions for treating anxiety disorders: A systematic review. J Affect Disord. 2017;210:1–13. https://doi.org/10.1016/j.jad.2016.12.005 . van Ballegooijen W, Cuijpers P, van Straten A, Karyotaki E, Andersson G, Smit JH, et al. Adherence to internet-based and face-to-face cognitive behavioural therapy for depression: A meta-analysis. PLoS ONE. 2014;9:e100674. https://doi.org/10.1371/journal.pone.0100674 . Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. J Anxiety Disord. 2018;55:70–8. https://doi.org/10.1016/j.janxdis.2018.01.001 . Grist R, Croker A, Denne M, Stallard P. Technology Delivered Interventions for Depression and Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis. Clin Child Fam Psychol Rev. 2019;22:147–71. https://doi.org/10.1007/s10567-018-0271-8 . Rooksby M, Elouafkaoui P, Humphris G, Clarkson J, Freeman R. Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: Systematic review and meta-analysis. J Anxiety Disord. 2015;29:83–92. https://doi.org/10.1016/j.janxdis.2014.11.006 . Tozzi F, Nicolaidou I, Galani A, Antoniades A. EHealth interventions for anxiety management targeting young children and adolescents: Exploratory review. JMIR Pediatr Parent. 2018;1:e5. https://doi.org/10.2196/pediatrics.7248 . MEXT (Ministry of Education, Culture, Sports, Science, and Technology). Realizing the GIGA school. Initiative; 2020. https://www.mext.go.jp/content/20200625-mxt_syoto01-000003278_1.pdf . Urao Y, Yoshida M, Sato Y, Shimizu E. School-based cognitive behavioural intervention programme for addressing anxiety in 10- to 11-year-olds using short classroom activities in Japan: A quasi-experimental study. BMC Psychiatry. 2022;22:658. https://doi.org/10.1186/s12888-022-04326-y . Radomski AD, Wozney L, McGrath P, Huguet A, Hartling L, Dyson MP, et al. Design and delivery features that may improve the use of Internet-based cognitive behavioral therapy for children and adolescents with anxiety: A realist literature synthesis with a persuasive systems design perspective. J Med Internet Res. 2019;21:e11128. https://doi.org/10.2196/11128 . Spence SH. A measure of anxiety symptoms among children. Behav Res Ther. 1998;36:545–66. https://doi.org/10.1016/S0005-7967(98)00034-5 . Ishikawa S, Sato H, Sasagawa S. Anxiety disorder symptoms in Japanese children and adolescents. J Anxiety Disord. 2009;23:104–11. https://doi.org/10.1016/j.janxdis.2008.04.003 . Nauta MH, Scholing A, Rapee RM, Abbott M, Spence SH, Waters A. A parent-report measure of children’s anxiety: Psychometric properties and comparison with child-report in a clinic and normal sample. Behav Res Ther. 2004;42:813–39. https://doi.org/10.1016/S0005-7967(03)00200-6 . Ishikawa S, Shimotsu S, Ono T, Sasagawa S, Kondo-Ikemura K, Sakano Y, et al. A parental report of Children’s Anxiety Symptoms in Japan. Child Psychiatry Hum Dev. 2014;45:306–17. https://doi.org/10.1007/s10578-013-0401-y . Grant M, Salsman NL, Berking M. The assessment of successful emotion regulation skills use: Development and validation of an English version of the Emotion Regulation Skills Questionnaire. PLoS ONE. 2018;13:e0205095. https://doi.org/10.1371/journal.pone.0205095 . Berking M, Wupperman P, Reichardt A, Pejic T, Dippel A, Znoj H. Emotion-regulation skills as a treatment target in psychotherapy. Behav Res Ther. 2008;46:1230–7. https://doi.org/10.1016/j.brat.2008.08.005 . Fujisato H, Ito M, Takebayashi Y, Hosogoshi H, Kato N, Nakajima S, et al. Reliability and validity of the Japanese version of the Emotion Regulation Skills Questionnaire. J Affect Disord. 2017;208:145–52. https://doi.org/10.1016/j.jad.2016.08.064 . Goodman R. The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry. 1997;38:581–6. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x . Matsuishi T, Nagano M, Araki Y, Tanaka Y, Iwasaki M, Yamashita Y, et al. Scale properties of the Japanese version of the Strengths and Difficulties Questionnaire (SDQ): A study of infant and school children in community samples. Brain Dev. 2008;30:410–5. https://doi.org/10.1016/j.braindev.2007.12.003 . Karyotaki E, Klein AM, Ciharova M, Bolinski F, Krijnen L, de Koning L, et al. Guided internet-based transdiagnostic individually tailored Cognitive Behavioral Therapy for symptoms of depression and/or anxiety in college students: A randomized controlled trial. Behav Res Ther. 2022;150:104028. https://doi.org/10.1016/j.brat.2021.104028 . Wirtz CM, Hofmann SG, Riper H, Berking M. Emotion regulation predicts anxiety over a five-year interval: A cross-lagged panel analysis. Depress Anxiety. 2014;31:87–95. https://doi.org/10.1002/da.22198 . MHLW (Ministry of Health, Labour and Welfare). Summary of the national survey of living conditions of the people; 2022. https://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa22/dl/03.pdf . MIC (Ministry of internal affairs and communications). National census; 2022. https://www.stat.go.jp/data/kokusei/2020/index.html . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted Reviews received at journal 02 Sep, 2024 Reviewers agreed at journal 22 Aug, 2024 Reviews received at journal 25 Jul, 2024 Reviewers agreed at journal 22 Jul, 2024 Reviewers invited by journal 21 Jul, 2024 Editor invited by journal 27 Jun, 2024 Editor assigned by journal 27 Jun, 2024 Submission checks completed at journal 27 Jun, 2024 First submitted to journal 25 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4638877","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":326198480,"identity":"d46ec8d5-2ce3-48a8-9f5c-cb53045572d7","order_by":0,"name":"Shoichi 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7","display":"","copyAsset":false,"role":"figure","size":13892,"visible":true,"origin":"","legend":"\u003cp\u003eChange in the mean SDQ-Total Difficulties scores.\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4638877/v1/db42ea4a2a54ffbbc1c1e401.jpg"},{"id":60713644,"identity":"7276e7fe-ca44-4709-93b4-435332e06a9d","added_by":"auto","created_at":"2024-07-19 20:37:30","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":15406,"visible":true,"origin":"","legend":"\u003cp\u003eChange in the mean SCAS-C scores in the high/low TDS groups.\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4638877/v1/1c79ad2e6e2a3e549a692f80.jpg"},{"id":60713645,"identity":"48c28687-2fcf-49ec-87fa-973406d0f6b4","added_by":"auto","created_at":"2024-07-19 20:37:30","extension":"jpg","order_by":9,"title":"Figure 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therapy","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAnxiety disorders are common psychiatric disorders that present in early childhood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with a lifetime prevalence of approximately 15\u0026ndash;20% in children and adolescents [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Merikangas et al. reported that approximately 1 in 3 adolescents met the diagnostic criteria for an anxiety disorder [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Anxiety disorders in childhood predict the maintenance of anxiety and other psychiatric disorders in adolescence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, anxiety disorders in adolescence also increase the risk of anxiety and depression in adulthood [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and predict other psychiatric disorders, such as alcoholism and chronic stress, and life situations, such as social maladjustment and low income [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Since anxiety disorders in children and adolescents rapidly increase between the ages of 10\u0026ndash;19 years [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], childhood prevention and early intervention are necessary [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Japan, anxiety problems are a factor contributing to the increasing trend of children not attending school. According to a survey conducted by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), approximately half (51.8%) the reasons for non-attendance were \u0026ldquo;apathy and anxiety,\u0026rdquo; with the proportion increasing each year [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Recent concerns regarding mental health problems among children have been linked to COVID-19 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which has led to increasing interest in addressing anxiety in schools. Meta-analyses have repeatedly confirmed the effectiveness of anxiety prevention approaches implemented in schools, which are also practical [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Prevention approaches include the universal approach, which is not targeted, and approach for at-risk or symptomatic individuals (Institute of Medicine (US) Committee on Prevention of Mental Disorders, 1994). Since the universal approach does not create labeling and stigmatization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], its adoption is appropriate to implement anxiety prevention programs in schools.\u003c/p\u003e \u003cp\u003eUrao et al. noted that child anxiety prevention programs developed in certain countries did not always demonstrate the expected effects in other countries. Subsequently, they developed a school-based universal anxiety prevention program called \u0026ldquo;Journey of the Brave,\u0026rdquo; based on cognitive behavioral therapy (CBT), tailored to the Japanese cultural and social context [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The program was conducted by teachers who received six hours of training via a facilitator\u0026rsquo;s manual [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, it was structured around the work that children did on their own, and the learning content was designed to be understood by teacher\u0026rsquo;s lectures and workbook reading. Previous studies suggested that school-based CBT programs were not as effective when delivered by teachers compared to by medical professionals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the \u0026ldquo;Journey of the Brave\u0026rdquo; program demonstrated effectiveness in reducing anxiety among 10\u0026ndash;12-year-olds even when presented by teachers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, in Japan, finding sufficient time to provide classes not stipulated by the MEXT was difficult. Furthermore, it placed a heavy burden on teachers in addition to in-class preparation. In addition, many schools suspended the program in 2021 owing to the COVID-19 pandemic that made it difficult to conduct face-to-face classes. Therefore, we considered ways to reduce the burden on schoolteachers and provide prevention programs flexibly.\u003c/p\u003e \u003cp\u003eInternet-delivered CBT (I-CBT) is an effective treatment for psychiatric disorders in children [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. I-CBT has received increasing attention owing to raised concerns regarding face-to-face treatment during the COVID-19 pandemic [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although not clearly defined, I-CBT can be broadly classified as guided or unguided and is a self-help format program with documents, audio, and video [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. I-CBT for anxiety disorders was more cost-effective than regular CBT treatment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Guided I-CBT is comparable to face-to-face treatment in terms of session completion rates [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], although it required approximately one-eighth of the therapist's time [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Its effectiveness was also comparable to face-to-face sessions for children with anxiety disorders [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, despite meaningful reports on the treatment, studies on I-CBT programs for prevention are scarce and warrant future research [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, we saw the potential of an e-learning version of the \u0026ldquo;Journey of the Brave\u0026rdquo; program. Since it was an individual work-based program with little interaction with teachers or classmates, it was relatively easy to convert written content into screen images. In addition, the Japanese government promoted a project called the GIGA (Global and Innovation Gateway for All) School Initiative [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] in response to the COVID-19 pandemic. Hence, most elementary and junior high schools now have one computer per student. Hence, if we can offer the program in a self-learning format through I-CBT, students can learn at their own pace at home or wherever they like, with teachers guiding them when necessary. If sufficient class time is unavailable, the program could be implemented flexibly, such as during self-study time, which could reduce the burden on teachers. A recent study on the \u0026ldquo;Journey of the Brave\u0026rdquo; reported reduced anxiety scores, even when the program was divided into short classroom activities of 20 minutes. This demonstrated that the program was effective without necessarily using 45\u0026ndash;50 minutes of classroom time at once [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Hence, we developed an e-learning version that allowed students to view class videos and answer work and tests over the Internet to make it more flexible and lower the burden on teachers owing to school implementation. \"Journey of the Brave\" is a school-based universal prevention program, and we envision an e-learning version also being offered in schools. However, simultaneously, fundamental verification is required to ensure that the e-learning version works correctly and that children can operate and understand it themselves as self-help material. Therefore, we aimed to evaluate the feasibility of the e-learning version at home rather than at school.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Aim and Setting\u003c/h2\u003e \u003cp\u003eThis study evaluated the feasibility of a newly developed e-learning version of \u0026ldquo;Journey of the Brave\u0026rdquo; via a single-arm intervention trial with no control group. Both parents and children participated. The intervention was provided only to the children; however, both completed a questionnaire to evaluate its feasibility. The study was approved by the Ethics Review Committee of Chiba University School of Medicine.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Participants\u003c/h2\u003e \u003cp\u003eParticipants were fifth- and sixth-grade students (aged 10\u0026ndash;12 years) enrolled in regular classes. Furthermore, the same parent answered all the questionnaires. Since this was a preventive intervention program, we excluded children who were not attending school, enrolled in special-needs classes, diagnosed with developmental disabilities or psychiatric disorders, or attended psychiatric hospitals. We recruited participants through the official \u0026ldquo;Journey of the Brave\u0026rdquo; website and flyers distributed to approximately 1,500 children through several schools in the Chiba and Ibaraki prefectures from August to September 2022. Applications and informed consent forms were available on the web. Furthermore, participants could apply only if they had read and agreed to the written instructions. A plain language children's assent document was also available on the web to ensure that both the parents and children were willing to participate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Intervention\u003c/h2\u003e \u003cp\u003eWe developed an e-learning version to replicate the classroom experience on a computer. Learning modules, called stages, comprised eight learning stages and a review stage, similar to the original (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Primarily, participants watched the videos and answered the questions in a workbook, with between one and five works per stage. Each stage included one core work and check tests that participants answered on the e-learning system so that the administrator could review the content. Furthermore, homework was provided for each stage. We asked participants to allow at least one week between two stages to work on homework, with a maximum study period of six months. However, we left the actual learning cycle up to them, which allowed for flexibility. In addition, although the e-learning system was designed so that participants could not proceed to the next stage unless they had completed the previous video or work; for homework assignments, participants were allowed to proceed even if they had not submitted the work. The e-learning version, which required children to learn at their own pace and on their initiative, had various features to encourage learning (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We employed a system whereby participants earned points upon completion of a stage and submitting the homework results. Participants earned new items and characters as they accumulated points and progressed through the levels. Participants could choose and display any characters acquired on the learning screen. We also sent a reminder message with content after they had completed stages 1, 3, and 8 to encourage continued learning. We also implemented a feature that allowed participants to ask questions when unsure. These features were developed based on previous research, which demonstrated that rewards, personalization, reminders, and a supportive environment from others in I-CBT programs increased children's adherence [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eContents by session\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstanding of four basic feelings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonitoring feelings of anxiety and setting goals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBody reactions and relaxation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety level stages and stair step exposure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety cognition model\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentify cognitive distortions and coping with rumination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive restructuring when anxious\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssertiveness skills to reduce social stress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview and summary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Procedure\u003c/h2\u003e \u003cp\u003eWe sent an e-learning account for each participating parent and child to the parent's e-mail address. When the children first logged onto the website to begin learning, we reaffirmed their assent by displaying an assent document that stated that they wished to learn on their own initiative and could withdraw at any time. Parents and children responded to a questionnaire that comprised the evaluation indicators three times: before the learning began (Pre), at the end (Post), and three months later (FU: Follow-up). We designed the questionnaire to be integrated into the learning process so that it would be clear when to respond. The first video was available after children had responded to the pre-study questionnaire. Conversely, we sent an e-mail to the parents when they had to respond to the questionnaire based on their children's learning progress. In addition, we set up the system so that parents could not only respond to the questionnaire, but also view the class videos so that they could see what their children would be learning. During the study period, we checked on the children's progress approximately once a week. If there was no access for \u0026gt;\u0026thinsp;10 days, we sent an e-mail to the parents to confirm that they were still interested in participating.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Measurements\u003c/h2\u003e \u003cp\u003eThe primary outcome was the dropout rate. We evaluated whether children completed the program even in its e-learning version. We also comprehensively evaluated its feasibility, which included the results of satisfaction questionnaires rated on a 4-point scale and learning scores as secondary outcomes. In addition, psychological scale scores were also used as secondary outcomes. We cannot discuss the effect of the intervention as this was a single-arm trial. However, we considered how anxiety and other scores changed over the study period as an essential feasibility component.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.5.1. Spence Children's Anxiety Scale (SCAS)\u003c/h2\u003e \u003cp\u003eThe SCAS assessed the severity of anxiety disorders in children [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and the validity of the Japanese version has been demonstrated [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Since parental ratings were also helpful in assessing children's anxiety [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], we used both, the scales that children answered themselves (SCAS-C) and those that parents answered regarding their children (SCAS-P) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Previous studies confirmed that classes with \u0026ldquo;Journey of the Brave\u0026rdquo; reduced the mean scores on the SCAS-C [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The SCAS-P was also used in studies during the program\u0026rsquo;s early development and found significant reductions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.5.2 EmotionRegulation Skills Questionnaire (ERSQ)\u003c/h2\u003e \u003cp\u003eThe ERSQ is the English version [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] of the Selbsteinsch\u0026auml;tzung Emotionaler Kompetenzen (SEK-27) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The Japanese version demonstrated reliability and validity in a previous study [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Hence, we used this scale as a secondary outcome, with supplementary explanations for difficult words for elementary school children to observe the multi-dimensional changes before and after e-learning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.5.3 Strengths and Difficulties Questionnaire (SDQ)\u003c/h2\u003e \u003cp\u003eThe SDQ comprised 25 items on five subscales that assessed children's emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Reliability and validity of the Japanese version, wherein parents responded regarding their children's anxiety, have been demonstrated [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The Total Difficulties Score (TDS), sum of the scores without the prosocial behavior subscale, had a maximum score of 40. A score of \u0026gt;\u0026thinsp;13 and \u0026gt;\u0026thinsp;16 were considered \u0026ldquo;some need\u0026rdquo; and \u0026ldquo;high need,\u0026rdquo; respectively. We used the TDS to observe the multi-dimensional changes in the child as perceived by the parents before and after the e-learning program.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Analysis\u003c/h2\u003e \u003cp\u003eThe dropout rate was calculated as the percentage of children who started the program and withdrew during the 6-month study period. We did not consider those who did not complete the program during the study period as they could continue it. We confirmed their intention to continue each time through the parents if there was no access for \u0026lt;\u0026thinsp;10 days. We obtained descriptive statistics from participants regarding satisfaction and from various learning records (e.g., checking test scores and number of homework assignments submitted). We analyzed continuous variables recording changes in psychological scale scores from Pre to FU via a repeated measures analysis of variance (ANOVA). Since the study purpose was to evaluate feasibility, it was also valuable to infer the type of children it would be more effective for and obtain findings that will contribute to future improvements. Therefore, we also compared two groups divided according to differences in psychological scale scores at the Pre time point. IBM SPSS Statistics version 28 was used for analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Dropout Rate\u003c/h2\u003e \u003cp\u003e Of the 46 parents and their children who agreed to participate, we excluded two pairs as one child was younger than the target grades and another withdrew before the Pre-questionnaire. Therefore, 44 pairs participated (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of these, four were single-mother families. Majority (19 (43.2%)) had a household income of \u0026gt;\u0026thinsp;9\u0026nbsp;million yen (\u003cspan\u003e$\u003c/span\u003e60,000). Furthermore, 34 (77.3%) fathers and 31 (70.5%) mothers had completed university or graduate school. Parents\u0026rsquo; average age was 44.4 years (38\u0026ndash;52 years), of whom only two (4.5%) were fathers and 42 (95.5%) were mothers. Since two children responded to the Pre-questionnaire yet withdrew without starting the e-learning program, 42 children, 29 (13 boys and 16 girls) and 13 (six boys and seven girls) in the fifth and sixth grades, respectively, actually started the study. Of these, 9 dropped out during their learning while one lost contact (dropout rate of 23.8%). Of the remaining 32 children, 28 completed the entire program, and the remaining four continued learning throughout the period and completed at least five or more stages (one completed five stages, one completed seven stages, and two completed eight stages). All 32 pairs also completed the Post- and FU questionnaires.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; demographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChildren's Information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (68.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReports from Parents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespondent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (95.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage Age of Respondents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.4 (38\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily Composition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParents and child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (90.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatherless family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Incomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u0026nbsp;million yen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;6\u0026nbsp;million yen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;9\u0026nbsp;million yen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;9\u0026nbsp;million yen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather\u0026rsquo;s Final Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational schools, junior colleges, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity or graduate school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (77.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother\u0026rsquo;s Final Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational schools, junior colleges, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity or graduate school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (70.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Satisfaction and Learning Records\u003c/h2\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the details of the Post and FU questionnaire responses regarding satisfaction. In total, 27 children (27/32, 84.4%) and 30 parents (30/31, 96.8%), and 26 children (26/31, 83.9%) and 30 parents (30/31, 96.8%) answered \u0026ldquo;agree\u0026rdquo; or \u0026ldquo;somewhat agree\u0026rdquo; to the overall satisfaction question in Post and in FU, respectively. The 28 children who completed all stages took an average of 13.6 weeks for completion (measured from Stage 1 completion owing to different lengths of time between questionnaire responses and starting Stage 1). The average score of the 29 children who answered the comprehension test (correct/incorrect questions) on all the content learned, which was provided in the last stage (Stage 9), was 14.6 out of 16 points (11\u0026ndash;16, SD\u0026thinsp;=\u0026thinsp;1.21). Conversely, the average number of times they submitted their homework was 8.6 times (of 15). Furthermore, there was a wide variation in their commitment to homework from 0\u0026ndash;15 times (SD\u0026thinsp;=\u0026thinsp;6.28).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Changes in Psychological scales\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the mean scores and standard deviations for each psychological scale from Pre to FU and results from repeated measures ANOVA. The 32 pairs who continued the program were analyzed. Data from children with missing items or responses were excluded. The mean SCAS-C score decreased by 4.37 points from Pre to FU (from 25.63 to 21.26); however, there was no significant difference between the three time points (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Conversely, the mean SCAS-P score decreased by 5.03 points (from 17.69 to 12.66), which indicated a significant difference between Pre and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, 95%CI= (-9.22, -0.84)) and Post and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004, 95%CI= (-7.50, -1.25)), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The mean ERSQ score increased by 9.24 points (63.45 to 72.69), which indicated a significant difference between Pre and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045, 95%CI= (0.18,18.31)) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The mean SDQ-TDS score rated by parents decreased by 1.9 points from Pre to Post (from 11.59 to 9.69 points), which indicated a significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025, 95%CI= (-3.62, -0.19)), and increased by 0.9 points from Post to FU. Thus, Pre and FU had no significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.67) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in the mean and standard deviation of each psychological scale.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre,\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost,\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFU,\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCAS-C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.63\u003c/p\u003e \u003cp\u003e(12.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.15\u003c/p\u003e \u003cp\u003e(14.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.26\u003c/p\u003e \u003cp\u003e(13.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCAS-P\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.69\u003c/p\u003e \u003cp\u003e(10.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.03\u003c/p\u003e \u003cp\u003e(7.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.66\u003c/p\u003e \u003cp\u003e(7.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.18**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERSQ\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.45\u003c/p\u003e \u003cp\u003e(20.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.38\u003c/p\u003e \u003cp\u003e(20.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.69\u003c/p\u003e \u003cp\u003e(18.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.39*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ-TDS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.59\u003c/p\u003e \u003cp\u003e(5.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.69\u003c/p\u003e \u003cp\u003e(5.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.59\u003c/p\u003e \u003cp\u003e(5.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.74*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eComparison of the scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003cp\u003e(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e95%CI of Mean difference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLower limit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUpper limit\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCAS-P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66 (1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.03* (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.38** (1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERSQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.93 (4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-15.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-9.24* (3.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-18.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.31 (3.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-12.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ-TDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.91* (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00 (0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.91 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSCAS-C/P, Spence Children\u0026rsquo;s Anxiety Scale Child/Parent version; ERSQ, EmotionRegulation Skills Questionnaire; SDQ-TDS, Strengths and Difficulties Questionnaire Total Difficulties Score.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Subgroup Analysis by Differences in Pre-intervention Scores\u003c/h2\u003e \u003cp\u003ePrevious research found that the high group (top 10% of pre-intervention SCAS-C scores) showed a significant decrease in scores compared to the low group [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this study, four children (9.1%) with SCAS-C scores of 45 or higher at Pre were considered a high group. However, two children and one child dropped out before the learning began and at Stage 1, respectively. Hence, subgroup analysis between high and low SCAS-C scores could not be performed. Therefore, we created a subgroup based on the SDQ-TDS at the Pre time point to evaluate differences in the SCAS-C and SCAS-P mean score changes at the three time points in each group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Interaction between score changes and group for the SCAS-C was insignificant for the high and low group with an SDQ-TDS score of \u0026gt;\u0026thinsp;13 and \u0026lt;\u0026thinsp;13, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.96) (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). However, a significant interaction was observed between score changes and group for the SCAS-P (F\u0026thinsp;=\u0026thinsp;3.73, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWithin-subject effects of the SCAS and SDQ-TDS.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSum of Squares\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eObserved Power\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCAS-C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e264.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e132.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime \u0026times; TDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.964\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eError\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3037.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCAS-P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e572.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e286.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime \u0026times; TDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e228.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e114.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eError\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1838.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Evaluation of E-learning Features\u003c/h2\u003e \u003cp\u003eIn addition to satisfaction, the questionnaire also enquired ratings of the various features on a scale from 1 to 10. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the average rating scores for each of the e-learning features. The reward and personalization features, which allowed users to obtain items and characters and choose which characters to display, respectively, received relatively high evaluations. Conversely, the homework feature, called \u0026ldquo;self-training,\u0026rdquo; received the lowest evaluation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of e-learning features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRating out of 10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage score of children\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAverage score of parents\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarn points\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObtain items and characters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChoose characters by themselves\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCan do \u0026ldquo;self-training\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive reminder messages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsk questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Feasibility\u003c/h2\u003e \u003cp\u003eWe developed and evaluated the feasibility of an e-learning version of the \u0026ldquo;Journey of the Brave\u0026rdquo; anxiety prevention program for children in Japan. The dropout rate was 23.8%. Of the participants, 76.2% and 66.7% completed at least five and all the stages, respectively. Furthermore, 83.9% of children and 96.8% of parents responded positively to the overall satisfaction level at FU. No other I-CBT study used an e-learning format where children with no apparent symptoms or problems took a universal anxiety prevention CBT program on an individual basis. Therefore, we cannot make comparisons. However, a study on university students with mild-to-moderate depression or anxiety symptoms (\u0026ldquo;ICare Prevent\u0026rdquo;) reported that 54.2% and 39.6% completed four or more and all seven sessions, respectively [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Furthermore, a meta-analysis of 64 trials that examined the effectiveness of I-CBT for patients with depression or anxiety disorders found a median adherence and satisfaction rate of 66% and 86%, respectively [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Compared to these studies, many parents and children viewed this program positively, despite the inclusion of participants who did not experience anxiety issues.\u003c/p\u003e \u003cp\u003eRegarding changes in psychological scale scores, a non-significant decrease was observed in the mean score for the SCAS-C; however, a significant decrease was observed for the SCAS-P from Pre to FU. These results were similar to those of a previous study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It was possible that an e-learning version could also significantly reduce the mean SCAS-C score if a larger sample was included, similar to the original program. We also observed a significant increase in the mean ERSQ scores from Pre to FU, which indicated that children's emotion regulation skills increased before and after the program's implementation. The e-learning program could have promoted children's emotion regulation skills. This was a novel finding. Emotion regulation skills could be a predictor of prevention effectiveness in anxiety prevention programs targeting non-clinical groups. Previous studies reported that emotion regulation was associated with the onset and maintenance of anxiety disorders [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These results supported the feasibility of the e-learning version based on its acceptability regarding low dropout rates and high satisfaction levels, as well as the expected effects of reduced anxiety and improved emotional regulation skills.\u003c/p\u003e \u003cp\u003eThe mean SDQ-TDS, which indicated difficulties stemming from children's emotional and behavioral problems, showed a significant decrease from Pre to Post. Conversely, the decrease was not maintained in FU. This indicated that the change was not sustained, at least regarding the child's specific problems observable from a parent's perspective. It was possible that since this program was essentially an anxiety prevention education program, its other problem-solving effects could have been limited. Hence, continuous verification is required to make a more accurate reference.\u003c/p\u003e \u003cp\u003eMost parents and children in the high SCAS-C score group dropped out without learning or dropped out early. Hence, we could not conduct subgroup analyses with high and low anxiety scores. We hypothesized that the e-learning version would also have a more significant effect on children with high anxiety. However, the population most likely to show a significant effect may not have accepted e-learning. Early dropouts may have resulted from an accidental outcome due to the small sample size or that highly anxious children felt burdened by the individualized learning experience. Clarifying the reasons they dropped out before learning and improving the e-learning to be more acceptable may deliver its effect to the high score group. The e-learning version may also have a pronounced anxiety reduction effect when implemented in schools, as in previous studies. Subgroup analysis by SDQ-TDS showed that the group of children considered to have support needs decreased significantly in mean scores on parent-rated anxiety (SCAS-P) from Pre to FU. This suggests that children with more difficulties in their daily lives could benefit from the program. However, there was no significant difference in the SCAS-C change. Hence, further examination with a larger sample size is required to make a more accurate reference.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Feature Improvements\u003c/h2\u003e \u003cp\u003eThese findings indicate that the design of a series of features based on rewards and personalization, such as earning points and level progression through learning, adding items and characters via progression, and selecting favorite characters to display, were highly rated. Conversely, the features for receiving messages were rated less highly. Children had to click several times to reach the dedicated message box to see the messages. In addition, a researcher had to manually send the messages as the system could not automatically send prepared messages owing to system limitations. We do not want teachers to be burdened with sending messages, especially when conducting e-learning in a school environment. Hence, ensuring that a message is automatically displayed when each stage is completed is a future requirement. We were also disappointed that the homework feature, an essential component, was not rated very highly and polarized the children into two groups: those who worked on very little and those who worked on almost everything. However, no previous study examined the extent to which children engaged in the homework associated with the program. These results suggest that considering ways to ensure that children wanted to continue doing homework could improve the quality of the program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Limitation\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the sampling issue. The participants might have been quite different from the classroom population where the program would be implemented as they were parents and children who willingly took the program. Furthermore, although the largest number of participants were from families with household incomes exceeding 9\u0026nbsp;million yen, the average annual income of households with children in Japan was 7.85\u0026nbsp;million yen [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Although \u0026gt;\u0026thinsp;70% of both parents who participated had a university or graduate school education, only 37.6% of men and 22.7% of women in their 40s in Japan had a university or graduate school education [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Hence, children who participated were raised by parents with high incomes and educational backgrounds, which may have influenced the children's lifestyle and attitudes toward e-learning. Second, we cannot inherently address the contribution of e-learning to changes in scores on psychological scales, including the anxiety preventive effect, as this was a single-arm study with no control group. We cannot assert that the positive changes were caused by e-learning, although we found significant positive changes in the SCAS-P and in ERSQ scores between Pre and FU. Furthermore, the reliability and validity of the Japanese version of the ERSQ has yet to be confirmed among elementary school students. However, we found no reason to doubt the feasibility of the e-learning version as we detected no adverse changes in any psychological scales, such as an increase in the mean anxiety score after the intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe study evaluated the feasibility of a newly developed e-learning version of the \u0026ldquo;Journey of the Brave\u0026rdquo; CBT-based anxiety prevention program, with 44 parent-child pairs. The study observed low dropout rates and high satisfaction from parents and children. We confirmed a specific feasibility, as it did not show any results contrary to expectations regarding reducing anxiety or improving emotional regulation skills. Verifying whether the e-learning version can show preventive effects of anxiety on the originally intended target population via comparison with a control group in a school environment is necessary.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCognitive behavioral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eI-CBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternet-based cognitive behavioral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpence Children's Anxiety Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERSQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmotion‑Regulation Skills Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengths and Difficulties Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMEXT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Education, Culture, Sports, Science and Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of variance.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the Ethics Review Committee of Chiba University School of Medicine in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects as well as the Declaration of Helsinki. Informed consent forms were available on the web which were filled out by the parents. A plain language children\u0026apos;s assent document was also available on the web to ensure that both the parents and children were willing to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by JSPS KAKENHI Grant Number 21K10934 and Osaka University\u0026apos;s \u0026ldquo;Developing Next-Generation Researchers who Devote Themselves to Challenging Research Projects,\u0026rdquo; which was selected for the \u0026ldquo;Support for Pioneering Research Initiated by the Next Generation\u0026rdquo; program by the Japan Science and Technology Agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSO contributed to all aspects of the study design, e-learning development, data collection, statistical analysis, and manuscript preparation. YU oversaw the study design and e-learning development and provided advice in manuscript preparation. KF made major contributions to the study design and statistical analysis. TK contributed to the study design. SI contributed to data collection and manuscript revision. ES reviewed\u0026nbsp;the study design and\u0026nbsp;the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the children and parents who participated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. 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National census; 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.stat.go.jp/data/kokusei/2020/index.html\u003c/span\u003e\u003cspan address=\"https://www.stat.go.jp/data/kokusei/2020/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"children’s anxiety, universal prevention program, internet-based cognitive behavioral therapy (I-CBT), e-learning, gamification, feasibility study","lastPublishedDoi":"10.21203/rs.3.rs-4638877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4638877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSchool-based cognitive behavioral therapy (CBT) programs could contribute toward preventing anxiety disorders in children. However, setting aside class time for such programs is difficult. Internet-based CBT (I-CBT) is an efficient way to provide CBT. However, studies on I-CBT for anxiety prevention are still scarce, including I-CBT for school-based universal prevention programs. Therefore, we developed an e-learning version of a school-based anxiety prevention CBT program \u0026ldquo;Journey of the Brave,\u0026rdquo; which was effective in Japan, to make it more flexible and accessible. This study evaluated its feasibility.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We conducted a single-arm study with 44 parents and children. Children aged 10\u0026ndash;12 took the e-learning program at home. Parents and children responded to a questionnaire three times: before the learning (Pre), after the learning (Post), and three months later (FU: Follow-up). Feasibility was comprehensively evaluated through dropout rates, satisfaction and learning records, and changes in scores on psychological scales.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 44 children, 42 started the e-learning, and 32 continued it (dropout rate of 23.8%). Furthermore, 83.9% of children and 96.8% of parents responded \u0026ldquo;agree\u0026rdquo; or \u0026ldquo;somewhat agree\u0026rdquo; regarding overall satisfaction. The parent-rated the Spence Children's Anxiety Scale \u003cb\u003e(\u003c/b\u003eSCAS) (SCAS-P) showed a significant decrease between Pre and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, 95%CI= (-9.22, -0.84)); however, the child-rated SCAS (SCAS-C) did not (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08). The Emotion‑Regulation Skills Questionnaire \u003cb\u003e(\u003c/b\u003eERSQ) also increased significantly between Pre and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045, 95%CI= (0.18, 18.31)). Total Difficulties Score of the Strengths and Difficulties Questionnaire \u003cb\u003e(\u003c/b\u003eSDQ) decreased significantly from Pre to Post (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025, 95%CI= (-3.62, -0.19)); however, it was not significantly different between Pre and FU (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.67).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe e-learning version showed low dropout rates and high satisfaction ratings from parents and children. Moreover, this study did not rule out the possibility that the program reduced children's anxiety and improved their emotional regulation skills. Therefore, its potential and feasibility were indicated.\u003c/p\u003e","manuscriptTitle":"Feasibility study of the e-learning version of the “Journey of the Brave”: A universal anxiety prevention program based on cognitive behavioral therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 20:37:25","doi":"10.21203/rs.3.rs-4638877/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-09-02T04:36:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203400819844125577763323777094047024515","date":"2024-08-22T09:11:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-25T12:47:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11985453287387282721827313254626042798","date":"2024-07-22T07:07:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-21T17:46:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-27T10:14:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-27T05:04:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-27T05:03:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-06-25T23:06:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4de36049-8916-4c13-a548-44b189f85ef9","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T15:59:30+00:00","versionOfRecord":{"articleIdentity":"rs-4638877","link":"https://doi.org/10.1186/s12888-024-06264-3","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2024-11-14 15:56:58","publishedOnDateReadable":"November 14th, 2024"},"versionCreatedAt":"2024-07-19 20:37:25","video":"","vorDoi":"10.1186/s12888-024-06264-3","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06264-3","workflowStages":[]},"version":"v1","identity":"rs-4638877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4638877","identity":"rs-4638877","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}