Evaluation of the Online Version of ‘Learn to Dare!’, a Cognitive-behavioral Intervention for Child Anxiety

Evaluation of the Online Version of ‘Learn to Dare!’, a Cognitive-behavioral Intervention for Child Anxiety | 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 Evaluation of the Online Version of ‘Learn to Dare!’, a Cognitive-behavioral Intervention for Child Anxiety Ellin Simon, Sara Scheveneels, Peter Verboon, Eva Hullu, Susan Hooren This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7926457/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Despite the proven efficacy of cognitive-behavioral therapy (CBT) for childhood anxiety, most anxious children do not receive treatment due to implementation barriers. Low-intensity online formats may help address this gap. This study examined the effectiveness of the online CBT-based program Learn to Dare! for children aged 8–13 with maladaptive anxiety, and explored the role of its components: psychoeducation, exposure (based on inhibitory learning), and cognitive restructuring. In a randomized controlled design, 92 children ( M age = 9.77, SD = 1.55) were assigned to the intervention ( n = 61) or a waitlist control group ( n = 31). Assessments took place pre- and post-intervention, and at 3-month follow-up. Anxiety, avoidance, and negative cognitions decreased over time in both groups, while positive cognitions remained stable. A larger proportion of intervention participants showed clinically significant improvement in anxiety levels compared to controls, though not on other measures. At follow-up, children in the intervention group were significantly less likely to meet diagnostic criteria for social anxiety disorder and generalized anxiety disorder, but not for other anxiety disorders. No consistent effects were found for individual components, except for an unexpected increase in avoidance after cognitive restructuring. Also of relevance, high attrition in this online CBT for child anxiety appeared related to higher baseline anxiety levels among drop-outs and limited user engagement. In sum, the online Learn to Dare! intervention appears beneficial for children with mild to moderate maladaptive anxiety who complete the intervention, and specifically those with social or generalized anxiety disorder. Child anxiety Avoidance Cognitions Online CBT Inhibitory learning Attrition Figures Figure 1 Figure 2 1.1 INTRODUCTION Anxiety is an adaptive emotional reaction to perceived imminent or anticipated threats. Anxiety can take many forms, such as fearful reactions in response to specific feared stimuli or worrying about certain topics. Despite its adaptive nature, a considerable number of children and adolescents exhibit troublesome levels of anxiety, or even meet the criteria of an anxiety disorder (AD). Among mental health disorders in children, AD’s prevail as the most common, with an estimated overall prevalence rate of 6.5% [1], which is likely to be an underestimation [2]. Of the common major AD’s, many have a median age of onset below 13 years [3]. The presence of AD’s can lead to substantial and chronic distress and impairment at an individual level [4], while also incurring significant societal costs [5]. AD’s are characterized by excessive avoidance behavior and dysfunctional cognitions. The behavioral aspect of anxiety primarily manifests as avoidance, which encompasses any action or series of actions undertaken by an individual to evade or anticipate unpleasant or distressing situations, stimuli, or events, including conditioned aversive stimuli [6]. Avoidance serves as an adaptive response aimed at enhancing survival [7]. However, when the stimuli being avoided are benign or when avoidance becomes excessive, hindering daily functioning, it becomes maladaptive [8; 9]. The presence of excessive avoidance is closely linked to the development [e.g., 10] and the continuity [e.g., 11] of maladaptive anxiety. Another hallmark of maladaptive anxiety concerns dysfunctional cognitions. According to the cognitive models utilized in cognitive-behavioral therapy (CBT), cognitive processes play a pivotal role in shaping behavioral and emotional reactions. Adults experiencing heightened levels of anxiety often exhibit a tendency to overestimate the likelihood of encountering threatening situations, while concurrently underestimating their own capacity to navigate and cope with such circumstances [12]. Various studies indicate the presence of comparable cognitive processes in children [2]. To disrupt the cycle of anxiety, avoidance, and dysfunctional cognitions, it is crucial to address elevated anxiety levels in children promptly and effectively. CBT stands out as the primary treatment for AD’s in youth [13]. A review spanning five decades of CBT for youth AD’s demonstrated substantial improvements from pre- to post-treatment, with around 65% becoming free of their primary AD after CBT [14; 15]. Despite the overall efficacy of CBT in treating childhood AD’s, implementation challenges, such as limited access to trained therapists, high costs, and stigma associated with seeking mental health treatment, result in many children not receiving this treatment [16]. To address these barriers, delivering CBT through low-level online formats could be a promising solution, potentially increasing accessibility, reducing costs, and offering flexible scheduling options [17]. CBT typically incorporates exposure and cognitive restructuring, involving facing anxiety-inducing situations and replacing unhelpful thoughts with functional ones, respectively. Despite CBT's well-established efficacy, there is limited understanding of its specific elements contributing to effectiveness. Creswell [2] notes a lack of examination regarding the link between CBT program activities and treatment outcomes, and emphasized the need for dismantling studies. The current study aims to contribute to this gap by examining the individual components of a comprehensive online CBT intervention. In this study, the exposure component for children is based on the inhibitory learning theory (ILT) instead of on habituation-based models. Child exposure therapy traditionally adheres to habituation principles, aiming to gradually diminish fear responses. In habituation-based exposure, a hierarchical approach is typically used, where children rank feared scenarios, systematically progressing from least to most feared. Moreover, the child would stay in the feared scenario until their fear has diminished [18]. Despite anxiety reduction, direct evidence supporting the tenability of the habituation model is mixed [19]. An alternative approach to exposure is the inhibitory learning account. Unlike habituation-based exposure, an inhibitory learning approach does not explicitly target anxiety reduction. It involves acquiring an additional inhibitory association that counteracts on the original excitatory fear association. Effective inhibitory learning involves challenging the child's expectations of the feared situation, emphasizing variability over predictable progression. Deliberately employing diverse stimuli, durations, intensities, and anxiety levels, inhibitory learning-based exposure stands out. Notably, studies that specifically incorporate variability to optimize inhibitory learning opportunities are scarce [20; 21; 22]. The present study examines the effectivity of an online CBT intervention "Learn to Dare!" [23], targeting children and adolescents with maladaptive anxiety using a randomized controlled trial (RCT) design that compared an intervention group with a waitlist control group (WL). Our study aimed to investigate to what extent the intervention is effective in reducing maladaptive anxiety in children and adolescents. We expected a more pronounced reduction in anxiety, avoidance and negative cognition levels among participants compared to those in the WL. In addition, we explored the unique contribution of psycho-education, exposure and cognitive restructuring on child anxiety in order to contribute to the dismantling of CBT for child anxiety. 2.1 METHOD 2.2. Design The study design was a randomized two-group (intervention versus WL) factorial design with repeated measures of the dependent variables. The assessments included a screening procedure, assessments before and after each of the intervention components (i.e., psycho-education, exposure and cognitive restructuring), as well as a three month follow-up. A detailed study design, procedure and analysis plan was described in a protocol paper [23] and were preregistered at https://osf.io/g2avh. In addition, all data and materials of this study were made publicly accessible at osf.io/d8c4p. 2.3 Participants We aimed at recruiting 8-13 year old children, who exhibited high levels of anxiety, specific phobias or other mild AD’s that are included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5, 24]. Substantial interference of major AD’s was the only exclusion criterion. We recruited our participants via the community (i.e., non-clinical/ non-referred) in the Netherlands. Figure 1 depicts the flow of participants over the course of the project from enrollment onwards. 2.4 Procedure This study received ethical approval from the METC azM/UM, METC173019, and was registered as a clinical trial at CCMO, NL 60801.068.17 (date: 05-16-2025). In line with ethical guidelines, participants were free to stop their participation at any time without having to provide a reason. Information, screening, interventions, and most evaluations took place on the 'Learn to Dare!' platform. Phase 1 of the study trajectory consisted of the recruitment, enrolment and randomization of participants. Recruitment of children was done through online advertisements, press releases, social media, magazine/publication features, and distribution of flyers at primary schools. Parents (and children aged 12 or older) submitted a signed informed consent form to the university, receiving account details via an automated email. Thereafter, the enrolment took place, consisting of two steps. In the first step of the selection procedure, the children filled out our screening questionnaire on the platform, the Youth Anxiety Measure for DSM-5 [YAM-5, 25], with distinct cut-offs for boys and girls to ensure gender proportionality. Non-high-anxious participants ( n = 38) were excluded, receiving guidance to general anxiety resources for children. In the second step of the selection procedure, high-anxious children took part in a diagnostic interview, the Structured Clinical Interview for DSM-5 Disorders for Children [SCID-5-Junior, 26]. The interview screened for severe (based on interference in daily life) AD’s requiring referral to professional mental healthcare. Consecutively, the high-anxious children were randomized to the intervention or WL. Importantly, all authors remained blind for randomization status of participants during all stages. We applied block randomization with the child's age and sex as strata. Phase 2 of the study trajectory consisted of the intervention and the assessments. Both groups underwent identical assessments: pretest (before the intervention group received psycho-education), pre-exposure test (before the intervention group received exposure and after they received psycho-education); pre-restructuring test (before the intervention group received cognitive restructuring and after they received exposure), posttest (after the intervention), and a 3-month follow-up. At all assessment points child anxiety, avoidance behavior, and positive and negative cognitions were measured. At pretest and follow-up, children took part in the diagnostic interview. The WL had the opportunity to engage in the intervention after the final assessment. Participants discontinuing the intervention were given the option to complete assessments voluntarily. 2.5 Intervention The online CBT-based program, titled 'Learn to Dare!,' addressed maladaptive child anxiety by targeting avoidance behavior and dysfunctional cognitions. The intervention took place on an online platform, and allowed for independent engagement of the children on an individual basis, irrespective of time and location. The child maintained a personalized online workbook, accessible only to the trainer, who controlled the progression of the intervention by releasing new intervention components. The intervention started with an introductory message exchange between the trainer and the participant, followed by psycho-education in session 1. Aligned with ILT, the exposure sessions (2 to 5) preceded the cognitive restructuring sessions (6 and 7). Exposure was set up in line with the ILT. The intervention concluded with relapse prevention and a farewell session (8). Before the intervention, the trainer selected two anxiety domains to target. Selection was based on SCID-Junior data, prioritizing DSM-5 diagnoses of specific phobias. If no specific phobia was present, other AD classifications were considered. When no DSM-5 diagnosis was available, YAM-5 data guided the selection, again giving preference to specific phobias. The two selected anxiety domains were then randomly assigned within the platform: one to be treated with exposure, the other with cognitive restructuring. Adherence was fostered through parental and trainer encouragement, with trainers receiving instructions and supervision from the primary author (participants remained blinded). Parents were briefed on the intervention's content and tasked with encouraging their child's progress. Each child received guidance from a personal trainer, holding a bachelor's degree in psychology. The trainers adhered to a detailed protocol and communicated with a child through private messaging. Privacy safeguards prevented access by interviewers or other researchers to the child's workbook. 2.6 Measurements The measurement tools included questionnaires and an interview. The questionnaires were embedded in the online ‘Learn to Dare!’ platform. The diagnostic interview was performed by telephone by interviewers who were blinded for randomization status. 2.6.1 Anxiety diagnoses The examination of prevalent DSM-5 disorders in childhood was conducted using the anxiety module of the SCID-5-Junior [26]. Children and their parents were interviewed separately by trained interviewers, which took approximately 20 minutes per interview. Interviewers reviewed the DSM-5 criteria for the presence of each AD. Initial findings on the tool’s psychometric qualities indicate satisfactory agreement between parent and child reports, as well as solid convergent validity [26]. 2.6.2 Anxiety level The assessment of child anxiety levels was done with the self-report version of the Youth Anxiety Measure for DSM-5 [YAM-5, 25], available at anxietymeasure.com. The YAM-5, designed for children aged 8–18 years, consisted of two parts. The initial section (28 items) addressed all major DSM-5 AD’s (e.g., the fear of going anywhere without parents), while the second segment (22 items) focused on specific phobias (e.g., fear of people dressed up in costumes). Participants rated items on a 4-point scale, ranging from 0 (never) to 3 (always). Earlier studies [e.g., 27] reported good internal consistencies, test-retest reliability, concurrent validity, and construct validity for the YAM-5. The internal consistency at pretest in the current study was: Cronbach’s α = 0.93, McDonald’s ω = 0.93. 2.6.3 Avoidance To examine avoidance related to anxiety, fear or worry in children, we utilized the Child Avoidance Measure Self report [CAMS, 28]. The CAMS consisted of eight items that were preceded by a general stem statement: “When I feel scared or worried about something …”. The items measure passive avoidance (e.g., “...I try not to go near it/avoid it”), active avoidance (e.g., “…I feel scared until I get away from it”), and refusal (e.g., “…I refuse to do it”), The items were scored on a 4-point scale (0 = “almost never” to 3 = “almost always”). The CAMS was translated and back-translated into Dutch. A recent study on the Dutch CAMS [29] confirmed the original CAMS’ sound psychometric properties. The internal consistency at pretest in the current study was: Cronbach’s α = 0.76, McDonald’s ω = 0.79. 2.6.4 Negative and positive cognitions Children's automatic negative and positive cognitions were evaluated using the Dutch version of the Children’s Automatic Thoughts Scale-Negative/Positive [CATS-N/P, 30]. Responses for all items are recorded on a 5-point scale, ranging from 0 (not at all) to 4 (all the time). Higher sum scores on Physical Threat, Social Threat, and Personal Failure indicated more negative cognitions; higher scores on Positive Cognitions indicated more positive cognitions. Hoogendoorn and colleagues [30] established robust psychometric properties for the CATS-N/P, reporting Cronbach's alpha values between .90 and .96 for the overall score. The internal consistencies in the current study for negative and positive cognitions respectively were Cronbach’s α = 0.95, McDonald’s ω = 0.95; Cronbach’s α = 0.92, McDonald’s ω = 0.92. 2.7 Analyses Due to a sample size smaller than initially intended, our study lacked the statistical power to fully scrutinize the comprehensive original research model outlined in Simon et al. [23]. Consequently, we were unable to assess whether the intervention's impact on child anxiety was mediated by reductions in avoidance behavior and dysfunctional cognitions. We performed analyses at group and at individual level. The analyses at group level were considered intention-to-treat analyses and were applied on imputed data till posttest. There were too many dropouts at the follow-up assessment, making any imputation method invalid. The analyses at the individual level were applied on complete data till posttest, and if data were also present of the follow-up assessment, we also included these data. Data preparation involved the following steps. First, missing data were imputed. For the analyses at the group level, we applied two imputation methods: 1) imputing the data from the previous assessment point; 2)imputing the mean between two assessment points. We reported the outcomes of the data where missing values were imputed by method 1, and mentioned whether the other imputation method yielded different results. We labelled the children who completed the assessments including posttest ‘completers’ ( n = 35). Second, outliers were winsorized to maximum values of M + - 3 SD . Third, the pretest data were checked for normality (skewness and kurtosis + - 1.5) after the outliers were removed. We applied non-parametric variants of the analytic tests if assumptions of normality were violated. The analyses at the group level were performed with a clinical dichotomous outcome measure (i.e.: diagnosis present versus diagnosis not present) as well as with continuous data (i.e., level of anxiety, avoidance, negative cognitions, positive cognitions). Chi-squared tests were applied to examine whether groups differed on frequency of the clinical dichotomous outcome measure diagnosis present versus diagnosis not present. In addition, we performed GLM repeated measures ANOVA consecutively with level of anxiety of major AD’s, level of anxiety of specific phobias, total level of anxiety, avoidance, negative cognitions and positive cognitions at the different time points (pre-, post-, and follow-up assessment) as within-subject factors and group (intervention group versus WL) as between-subjects-factor. In case the assumption of sphericity was violated, we applied a Greenhouse-Geisser correction. Partial eta squared were used as effect sizes, where small effects are indicated by an η 2 p of approximately .01, medium effects by an η 2 p of approximately .06 and large effects of η 2 p of approximately .14 [31]. We applied a .05 significance level and used Jamovi to perform these analyses. For the analyses at the individual level, we adopted an alternative, the Reliable Change Indices (RCI, 32; 33; 34], to assess the effectiveness of these interventions. Unlike standard pre-post treatment evaluations, this approach not only measures the statistical significance of “changes”, but also evaluates their clinical relevance. By offering a more precise indication of clinical changes, it supports health providers in making individualized decisions [35]. Considering the significant variability in symptoms and progression, applying and assessing interventions on an individualized basis appeared to be a suitable approach. An individual’s change was considered a clinically significant positive change if RCI > 1.96 and a clinically significant negative change if RCI < -1.96. We used Microsoft Windows Excel to perform these analyses. 3.1 RESULTS 3.2 Descriptives The participating children ( n = 92) had a mean age of 9.77 ( SD = 1.55). The sample consisted of 42 boys (46%) and 50 girls (54%). Regarding diagnostic information, there were 54 children (59%) with one or more DSM-5 AD’s at pretest. The three most commonly diagnosed AD’s at pretest were: specific phobia ( n = 36, 39%), generalized AD ( n = 19, 21%), and social AD ( n = 12, 13%). We checked whether the groups were comparable at the pretest. There were no differences on demographic features, presence of AD’s, type of AD’s, level of anxiety, negative cognitions, positive cognitions, nor on the presence or type of AD’s between children who were randomized to the intervention group and those randomized to the WL, all p ’s > .10. However, it appeared that children in the intervention group had significantly lower avoidance scores at pretest than children in the WL, Mann-Whitney U = 641, p = .004. When checking for differences between boys and girls at pretest, we found that separation AD was diagnosed more frequently in girls ( n = 8, 16%) than in boys ( n = 1, 2%), χ 2 (1) = 4.80, p = .036. There were no other pretest differences between boys and girls, all p ’s > .10. The descriptive statistics of anxiety level, avoidance and positive and negative cognitions are shown in Table 1 and the pretest correlations between these variables are depicted in Table 2. Table 1 Development of Anxiety a , Avoidance b , Negative and Positive Cognitions c of Waitlist Control Group (n = 31) and Intervention Group (n = 61) Pretest Before exposure Before cognitive restructuring Posttest Waitlist ( M, SD ) Intervention ( M, SD ) Waitlist ( M, SD ) Intervention ( M, SD ) Waitlist ( M, SD ) Intervention ( M, SD ) Waitlist ( M, SD ) Intervention ( M, SD ) Level of anxiety Major anxiety disorders 29.70 (16.00) 25.90 (12.00) 28.80 (15.80) 25.10 (11.70) 25.70 (16.00) 23.40 (11.70) 25.10 (15.50) 22.80 (12.40) Level of anxiety Specific phobias 22.30 (10.80) 18.60 (9.65) 23.30 (11.60) 17.80 (10.20) 22.10 (11.50) 17.80 (10.00) 21.70 (11.20) 17.20 (10.70) Total level of anxiety 51.30 (23.80) 44.50 (18.50) 51.90 (25.20) 42.70 (19.10) 47.40 (25.40) 41.30 (18.90) 46.60 (25.20) 40.00 (20.70) Avoidance 13.90 (5.01) 9.95 (7.94) 7.52 (6.73) 6.48 (7.08) 11.50 (7.14) 6.83 (7.61) 12.30 (6.92) 14.00 (4.62) Negative cognitions 28.80 (20.70) 22.80 (16.20) 27.80 (21.10) 19.40 (16.00) 25.50 (21.70) 18.60 (16.20) 23.10 (20.40) 18.00 (16.40) Positive cognitions 16.70 (10.90) 17.60 (9.40) 16.30 (10.80) 17.00 (9.51) 17.30 (11.00) 17.40 (9.61) 16.80 (10.70) 16.60 (8.53) Note. a Measured with the YAM-5, b measured with the CAMS, c measured with the CATS-N/P. Table 2 Pretest correlations between major anxiety disorders’ anxiety level (MAD), specific phobias’ anxiety level (SP), total anxiety level, avoidance, and positive and negative cognitions MAD SP Total level of anxiety Avoidance Negative cognitions Positive conditions MAD 1 - - - - - SP .62 *** 1 - - - - Total anxiety level .92 *** .87 *** 1 - - - Avoidance .01 .12 .05 1 - - Negative cognitions .74 *** .52 *** .72 *** .01 1 - Positive cognitions -.18 -.09 -.14 .11 -.36 *** 1 Note. *** p < .001. 3.3 Evaluation of the intervention At the posttest, 19 children who participated in the intervention were asked about how they experienced the intervention. The results of this evaluation are depicted in Table 3. Additionally, there were twelve children who voluntarily reported their reason for ending their participation in the intervention. Their answers could be categorized as follows: child disliked the intervention: n = 4 (33%); child made enough progress: n = 3 (25%); child was not motivated anymore: n = 3 (25%); child thought the training was not suitable for his/her fears: n = 1 (8%); child disliked completing the questionnaires that were part of the larger study: n = 1 (8%). Table 3 Children’s (n = 19) Evaluation of the Intervention (grades: 1: extremely bad; 10 extremely good) What grade do you give to… Grade (1-10) ( M, SD ) …the entire intervention)? 8.21 (1.13) …your trainer? 9.16 (1.01) …the difficulty of the intervention? 5.37 (2.43) …the exposure sessions? 7.45 (1.61) …the cognitive restructuring sessions? 6.71 (2.61) 3.4 Effectiveness of the intervention With respect to diagnostic data, we examined whether the intervention and WL differed on the presence of AD’s at post-test. Whereas the groups did not differ on the presence of AD’s, nor on the type of AD’s, both p ’s > .10, we found there were less classifications of social phobia at posttest in the intervention than in the WL, χ 2 (1) = 10, p = .002, and less classifications of generalized AD, χ 2 (1) = 10, p = .002. No other differences regarding the presence of AD’s were present between the groups, all p ’s > .10. Regarding the other clinical outcome measures, we compared the development of anxiety levels, avoidance and negative and positive cognitions in intervention and WL children. The intention-to-treat-analyses showed the following outcomes. The major AD’s anxiety level decreased significantly over time, F (2.33) = 12.98, p < .001, η 2 p = .13, but there was no significant difference between groups over time, F (2.33) = .66, p = .54, η 2 p = .01. The specific phobias’ anxiety level did not decrease significantly over time, F (2.20) = 1.46, p = .23, η 2 p = .02, and the groups did not differ in their course over time, F (2.20) = 1.09, p = .34, η 2 p = .01. The total level of anxiety decreased significantly over time, F (3) = 8.75, p < .001, η 2 p = = .09, but there was no significant difference between groups over time, F (3) = .70, p = .55, η 2 p = .01. Avoidance changed significantly over time, F (3) = 20.48, p < .001, η 2 p = .19. and the groups differed significantly in their course over time, F (3) = 5.86, p < .01, η 2 p = .06. Post-hoc tests showed a significant increase in avoidance in the intervention group after the intervention group received cognitive restructuring, t (59) = 629, p < .001, Cohen’s d = .81, while avoidance in the WL did not increase significantly after this assessment point, W (30) = 21, p = .54. Negative cognitions decreased significantly over time, F (3) = 10.32, p < .001, η 2 p = .11, but the groups did not differ in their course over time, F (3) = .06, p = .64, η 2 p = .01. Positive cognitions did not change significantly over time, F (3) = .52, p = .67, η 2 p = .01, and groups did not differ in their course over time, F (3) = .10, p = .96, η 2 p = = .001. The results were comparable when the other imputation method was applied, except for avoidance. That is, when missing values were imputed with the mean between time points, avoidance did decrease significantly over time, F (2.50) = 7.93, p < .001, η 2 p = .12, but the courses of avoidance did not differ significantly between groups, F (2.50) = 1.6, p = .32, η 2 p = .02. Within the group of completers, we also examined the effectiveness of the intervention by calculating RCI’s for anxiety level, avoidance and negative as well as positive cognitions. First, we checked whether completers differed from drop-outs on anxiety level, avoidance, negative and positive cognitions at pretest. It appeared that completers had significantly lower anxiety levels ( M = 41.3, SD = 18.27) than drop-outs ( M = 50.1, SD = 21.2) at pretest, t (87) = 2.01, p = .047, and completers had significantly lower negative cognitions at pretest ( M = 18.6, SD = 13.14), than drop-outs ( M = 28.9, SD = 20.72), Mann-Whitney U = 561, p = .013. No other differences between completers and drop-outs were found, all p’ s > .05. With respect to the effectiveness of the intervention in the group of completers, it was found that more children of the intervention group made a clinically significant improvement on child anxiety level, 33% ( n = 8) than children of the WL, 18% ( n = 2), whereas 8% ( n = 2) of the children of the intervention group deteriorated clinically significantly versus 0% of the children of the WL. The Jacobson-Truax plot (Figure 2) depicts the RCI’s of child anxiety of the intervention and the WL groups. Regarding avoidance, 0% of the children in both groups made a clinically significant improvement, whereas 5% ( n = 1) of the children of the intervention deteriorated clinically significantly versus 0% of the children of the WL. With regard to negative cognitions, 21% ( n = 5) of the children of the intervention group made a clinically significant improvement and 22% ( n = 2) of the children of the WL, whereas 4% ( n = 1) of the children of the intervention group deteriorated clinically significant versus 0% of the children of the WL. With respect to positive cognitions, 4% ( n = 1) of the intervention group and 0% of the WL made a clinically significant improvement, whereas 22% ( n = 5) of the intervention group and 22% ( n = 2) of the WL deteriorated clinically significantly. 4.1 DISCUSSION This study evaluated the effectiveness of the online CBT-based intervention ‘Learn to Dare!’ in reducing maladaptive anxiety in children and adolescents using a randomized controlled trial with a WL condition. We hypothesized that participants in the "Learn to Dare!" intervention would show greater reductions in anxiety diagnoses and anxiety, avoidance and negative cognition levels compared to the WL. Children in the intervention group were significantly less likely to meet diagnostic criteria for social AD and generalized AD than children in the WL at follow-up. No group differences were found for other AD’s at follow-up. Anxiety level, avoidance and negative cognitions declined equally in both groups, whereas positive cognitions were not affected by time nor by intervention. However, when examining children who completed all assessments, a higher proportion of children in the intervention group made a clinically significant improvement on anxiety level. In sum, these findings offer partial support for our hypothesis. Specifically, we observed a reduction in diagnoses of social anxiety disorder (SAD) and generalized anxiety disorder (GAD) within the intervention group, and favorable outcomes were particularly evident among children who completed the full program. In contrast to the online version of Learn to Dare!, the face-to-face version [36] was found to be consistently effective across different types of anxiety diagnoses, with more robust and uniform outcomes. The face-to-face version of ‘Learn to Dare!’ differed from the online version of ‘Learn to Dare!’ in how it was delivered in three ways: the face-to-face version was offered in group format, it did not contain online elements, and exposure adhered to habituation. With respect to offering CBT for child anxiety individually or in group format, meta-analyses [13; 37] reveal no differences in effectiveness. We, therefore, argue that the unique findings of the online version of ‘Learn to Dare!’ may be attributed to its online character and/or to the fact that exposure was provided in line with the inhibitory learning theory (ILT). Regarding the online character of the current intervention, meta-analyses [e.g., 38] show that online interventions for child anxiety are generally effective in the short term. For social AD, Nordh et al. [39] found that online CBT not only reduced symptoms but was also cost-effective. However, long-term effects remain unclear [40], and many youths prefer face-to-face treatment [41; 42]. More research is needed to determine which delivery format suits whom. Comparing online, face-to-face, and blended CBT formats is also relevant. Blended care, combining in-person and digital elements, has proven more effective than online intervention in adults [43] and is seen as optimal for depressed children [44], though evidence for anxious children is still limited [45]. With respect to offering exposure in ILT format, this study represents a novel contribution to the field. ILT posits that the efficacy of exposure is primarily driven by expectancy violation, whereby individuals are encouraged to articulate their core fearful expectation, and then engage in exposure exercises designed to maximally disconfirm these expectations. Although the intervention as a whole was found to be beneficial on certain outcome measures, findings did not reveal a specific positive or negative contribution of exposure on child anxiety, avoidance or positive and negative cognitions. Despite our attempts to facilitate the exposure process by introducing a video-model, a playful metaphor and support by the trainer, a critical observation during the study was the difficulty a substantial number of children experienced in verbalizing their fearful expectations. This observation raises important questions about the developmental appropriateness and practical feasibility of ILT-based exposure in younger populations. Furthermore, the ILT-based exposure protocol may have posed greater challenges compared to traditional habituation-based approaches. Key elements, such as the discouragement of safety behaviors, and the use of a variable rather than a hierarchical approach, may have contributed to participants’ perceived difficulty of the intervention and the high attrition rates observed. These challenges were potentially exacerbated by the online, self-guided format of the intervention, which may have been particularly demanding for high-anxious 8-13 year olds. Future research is warranted to further investigate the suitability of ILT-based exposure for pediatric populations and when using online formats. While the online intervention showed positive effects for some children, a small number experienced clinically significant deterioration, particularly in avoidance and positive cognitions. These findings are consistent with previous research indicating that psychotherapy can have adverse effects in a minority of cases [46]. This highlights the importance of monitoring negative outcomes, especially in online formats. As outlined in our protocol paper [23], we initially aimed to conduct a dismantling study. However, due to the limited sample sizes, we were only able to explore—rather than isolate—the contributions of psychoeducation, exposure, and cognitive restructuring. Avoidance increased following cognitive restructuring, which aligns with findings by Stiede et al. [47], who argue that cognitive techniques may slow learning, and by Whiteside et al. [48], who suggest that strategies like positive distraction and thought stopping can reinforce avoidance. No specific effects of the individual components were found on other outcome measures. Notably, children who completed the intervention showed clinical improvements in anxiety level, unlike those who dropped out—suggesting that the combination of psychoeducation, exposure, and cognitive restructuring may have a synergistic effect. Given the considerable efforts we made to promote participant enrollment in the intervention and to minimize dropout, we consider the high attrition rate in this study as a side effect of the study/intervention rather than a limitation. Therefore, we inspected the attrition rates throughout the study, examined features of children who dropped out and evaluated the voluntary feedback from drop-outs. We identified several interesting findings that may be related to the high attrition observed in this online CBT for child anxiety. First, 60% of the participants who initially showed interest in the study choose not to participate in the study after receiving the voluminous informed consent packages. Although awareness of the importance of clinical trials in children has grown within both the scientific community and the general public, conducting such trials remains difficult. This is largely due to the more complex and stringent requirements for obtaining consent in children compared to adults [49]. The participation rate of children in scientific research could be improved if medical ethics review boards were to permit and promote more patient-friendly communication. Second, it appeared that children who completed the online intervention had lower levels of anxiety and negative cognitions before the start of the intervention than children who dropped-out. This is in line with previous research indicating higher acceptability of online treatment for people with mild to moderate symptoms than for people with severe symptoms [50]. This could indicate that online CBT-interventions, such as ‘Learn to Dare!’ may be specifically appropriate as waitlist intervention, or for prevention and early intervention purposes. Third, although the intervention was generally well-liked, children who dropped out most often cited a dislike of the intervention. Since online interventions for child anxiety remain a promising avenue to increase the number of anxious children receiving help, it is of essence to enhance user engagement and facilitate the adoption of internet-based treatments. Future research can investigate the effect of adding game-like features to the online format, such as in-game rewards and badges, which may increase the appeal of the intervention and treatment engagement [51]. In addition, future developers of online interventions are encouraged to engage intended end users in the development process through user-centered design and usability testing [52]. One way to understand the results of our study and the high attrition rate is to consider the paradigmatic assumptions underlying our research design. A common assumption in psychotherapy research has been that change is gradual and linear, yet emerging evidence suggests that psychological change often follows nonlinear, dynamic patterns [53]. Our study design reflects the linear assumption through predetermined measurement intervals and the expectation of predictable intervention effects. From a dynamic systems perspective, participants are not passive recipients but actively shape their own development and utilize the intervention as a resource for their own goals [54]. This may explain why some children discontinued the intervention: not due to passive "dropout," but due to an active decision that the intervention did not align with their own change process. These insights call for a fundamental reconsideration of how we design intervention studies. As Deisenhofer et al. [55] argue, implementing precision methods requires moving beyond traditional assumptions about homogeneous treatment responses, understanding change as a complex, self-organizing process rather than as a linear consequence of our interventions. 4.2 Limitations The findings of this study should be interpreted in light of its limitations. First, we originally aimed to conduct a dismantling study with multiple assessments and outcomes, but small sample sizes limited us to an exploratory analysis of the CBT components. The fact that dismantling requires large-scale new studies to be carried out [56], appears to impede the conduct of such studies. Indeed, experimental dismantling studies on CBT for child anxiety have rarely been performed [see reviews: 57; 48], despite repeated calls for this type of study [e.g., 14]. Second, we used Reliable Change Indexes (RCIs) as an alternative to the original analytical approach. While this allowed for an exploratory look at individual-level change, we acknowledge that RCIs have notable limitations. Critics highlight their low sensitivity to real change, reliance on only two time points, and potential for misinterpretation—especially when reliability estimates are suboptimal [58]. Although the RCI offered a practical solution in our context, future research would benefit from more robust longitudinal methods where possible, such as latent change score models or multilevel growth models [59; 60]. Third, while some children who dropped out shared their reasons, the information is limited. Most cited a general dislike of the intervention, but the specific reasons for this dislike remain unclear. This lack of detailed feedback hinders our ability to improve the training to reduce dropout and limits its value for future research. 4.3 Clinical implications The findings suggest that the online version of ‘Learn to Dare!’ may be a valuable option for children with milder anxiety and less negative cognitions (e.g., during waitlist periods), or for children with social AD or generalized AD. For these groups, the accessible and self-guided nature of the intervention may be sufficient to achieve meaningful improvements. In contrast, children with more severe anxiety may benefit from the real-time guidance and support of a therapist, especially during exposure. Depending on symptom severity and individual needs, face-to-face or blended interventions for child anxiety may offer additional advantages. 4.4 Conclusion In conclusion, the current study provides partial support for the effectiveness of the online CBT-based intervention "Learn to Dare!" in reducing maladaptive anxiety among children and adolescents. That is, the intervention group showed significantly better outcomes for anxiety levels among children who completed all assessments, and for social and generalized AD’s at follow-up. Declarations Human Ethics and Consent to Participate Declaration This study was reviewed and approved by the METC azM/UM, METC173019, and was registered as a clinical trial via CCMO, NL 60801.068.17. Written informed consent was obtained from the legal guardians of all participating children prior to participation. Children aged 12 years and older also provided written informed consent prior to participation. All procedures were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki. Funding Declaration This study was funded by Mind Netherlands (grant number 2015 7025), Stationsplein 125, 3818 LE Amersfoort, The Netherlands. The funding body approved the study design but had no role in the collection, analysis, or interpretation of the data, nor in the writing of the manuscript. Author Contribution Ellin Simon wrote the main manuscript text and performed the main analysesSara Scheveneels wrote parts of the discussion and reviewed the manuscriptPeter Verboon performed a simulated power analyses, and worked conjointly with the first author on the analysesEva de Hullu wrote parts of the discussion and reviewed the manuscriptSusan van Hooren reviewed the manuscript and supervised the proces. Data Availability In addition, all data and materials of this study were made publicly accessible at osf.io/d8c4p. References Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56:345–65. Creswell C, Waite P, Hudson J. Practitioner review: anxiety disorders in children and young people – assessment and treatment. J Child Psychol Psychiatry. 2020;61:628–43. Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. 2022;27:281–95. Asselmann E, Wittchen HU, Lieb R, Beesdo-Baum K. Sociodemographic, clinical, and functional long-term outcomes in adolescents and young adults with mental disorders. Acta Psychiatr Scand. 2018;137:6–17. Bodden DH, Dirksen CD, Bögels SM. 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Montero M, Iraurgi I, Matellanes B, Montero JM. Use of the reliable change index to evaluate the effectiveness of clinical interventions: application of an asthma training program. Aten Primaria. 2015;47(10):644–52. Simon E, Bögels SM, Voncken JM. Efficacy of child-focused and parent-focused interventions in a child anxiety prevention study. J Clin Child Adolesc Psychol. 2011;40(2):204–19. Ewing DL, Monsen JJ, Thompson EJ, Cartwright-Hatton S, Field A. A meta-analysis of transdiagnostic cognitive behavioural therapy in the treatment of child and young person anxiety disorders. Behav Cogn Psychother. 2015;43(5):562–77. Csirmaz L, Nagy T, Vikor F, Kasos K. Cognitive behavioral digital interventions are effective in reducing anxiety in children and adolescents: a systematic review and meta-analysis. J Prev. 2024;45(2):237–67. Nordh M, Wahlund T, Jolstedt M, Sahlin H, Bjureberg J, Ahlen J, et al. Therapist-guided internet-delivered cognitive behavioral therapy vs internet-delivered supportive therapy for children and adolescents with social anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2021;78(7):705–13. Jolstedt M, Vigerland S, Mataix-Cols D, Ljótsson B, Wahlund T, Nord M, et al. Long-term outcomes of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders: towards a stepped care model of health care delivery. Eur Child Adolesc Psychiatry. 2021;30(11):1723–32. Smart H, O’Connor M, McDermott B. Young people’s perspectives on digital versus face-to-face therapy for anxiety: a qualitative study. Behav Res Ther. 2023;163:104157. Sweeney GM, Donovan CL, March S, Forbes Y. Logging into therapy: parent and adolescent acceptability of online mental health treatment. Internet Interv. 2019;15:93–9. Erbe D, Eichert HC, Riper H, Ebert DD. Blending face-to-face and internet-based interventions for the treatment of mental disorders in adults: systematic review. J Med Internet Res. 2017;19(9):e306. Rasing SP. Blended treatment for depressive disorders in youth: a narrative review. Int J Cogn Ther. 2021;14(1):47–58. Nunes-Zlotkowski KF, Shepherd HL, Beatty L, Butow P, Shaw JM. Blended psychological therapy for the treatment of psychological disorders in adult patients: systematic review and meta-analysis. Interact J Med Res. 2024;13(1):e49660. Strauss B, Gawlytta R, Schleu A, Frenzl D. Negative effects of psychotherapy: estimating the prevalence in a random national sample. BJPsych Open. 2021;7(6):e186. Stiede JT, Trent ES, Viana AG, Guzick AG, Storch EA, Hershfield J. Cognitive behavioral therapy for children and adolescents with anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2023;32(3):543–58. Whiteside SP, Sim LA, Morrow AS, Farah WH, Hilliker DR, Murad MH, Wang Z. A meta-analysis to guide the enhancement of CBT for childhood anxiety: exposure over anxiety management. Clin Child Fam Psychol Rev. 2020;23:102–22. Joseph DP. Clinical trials in children: equity, quality and relevance. [place unknown]: [publisher unknown]; 2015. Gun SY, Titov N, Andrews G. Acceptability of internet treatment of anxiety and depression. Australas Psychiatry. 2011;19(3):259–64. Christie GI, Shepherd M, Merry SN, Hopkins S, Knightly S, Stasiak K. Gamifying CBT to deliver emotional health treatment to young people on smartphones. Internet Interv. 2019;18:100286. Hill C, Reardon T, Taylor L, Creswell C. Online support and intervention for child anxiety (OSI): development and usability testing. JMIR Form Res. 2022;6(4):e29846. Hayes AM, Laurenceau JP, Feldman G, Strauss JL, Cardaciotto L. Change is not always linear: the study of nonlinear and discontinuous patterns of change in psychotherapy. Clin Psychol Rev. 2007;27(6):715–23. Griffiths R, Huddy V, Eaton S, Waldorf J, Mansell W. Rethinking secondary mental healthcare: a perceptual control theory perspective. London: Taylor & Francis; 2024. Deisenhofer AK, Barkham M, Beierl ET, Schwartz B, Aafjes-van Doorn K, Beevers CG, et al. Implementing precision methods in personalizing psychological therapies: barriers and possible ways forward. Behav Res Ther. 2024;172:104443. Leijten P, Weisz JR, Gardner F. Research strategies to discern active psychological therapy components: a scoping review. Clin Psychol Sci. 2021;9(3):307–22. Dunning EE, Khan AN, Becker-Haimes EM, Guzick AG. When attempts to help backfire: psychosocial interventions that may inadvertently prolong anxiety among youth. Res Child Adolesc Psychopathol. 2025;1–15. McAleavey AA. When (not) to rely on the reliable change index: a critical appraisal and alternatives to consider in clinical psychology. Clin Psychol Sci Pract. 2024;31(2):e12988. Gee KA. Multilevel growth modeling: an introductory approach to analyzing longitudinal data for evaluators. Am J Eval. 2014;35(4):543–61. McArdle JJ. Latent variable modeling of differences and changes with longitudinal data. Annu Rev Psychol. 2009;60(1):577–605. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Mar, 2026 Reviews received at journal 01 Mar, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviews received at journal 14 Jan, 2026 Reviewers agreed at journal 28 Dec, 2025 Reviewers agreed at journal 26 Dec, 2025 Reviewers invited by journal 26 Dec, 2025 Editor invited by journal 10 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 08 Dec, 2025 First submitted to journal 22 Oct, 2025 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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1","display":"","copyAsset":false,"role":"figure","size":57826,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant rates throughout the study trajectory.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7926457/v1/b309309dd1998cd7d83049f8.png"},{"id":99319106,"identity":"026db385-661c-40cc-9ae3-251198c6efa4","added_by":"auto","created_at":"2025-12-31 16:36:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":107873,"visible":true,"origin":"","legend":"\u003cp\u003eReliable change indices between pretest (pre) and posttest (post) for child anxiety.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7926457/v1/f7cfa682db2728e80614b6ab.png"},{"id":99788572,"identity":"23e6ac99-4ec3-4e01-8b01-a7cac62a1eb5","added_by":"auto","created_at":"2026-01-08 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Anxiety can take many forms, such as fearful reactions in response to specific feared stimuli or worrying about certain topics. Despite its adaptive nature, a considerable number of children and adolescents exhibit troublesome levels of anxiety, or even meet the criteria of an anxiety disorder (AD). Among mental health disorders in children, AD\u0026rsquo;s prevail as the most common, with an estimated overall prevalence rate of 6.5% [1], which is likely to be an underestimation [2]. Of the common major AD\u0026rsquo;s, many have a median age of onset below 13 years [3]. The presence of AD\u0026rsquo;s can lead to substantial and chronic distress and impairment at an individual level [4], while also incurring significant societal costs [5]. AD\u0026rsquo;s are characterized by excessive avoidance behavior and dysfunctional cognitions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe behavioral aspect of anxiety primarily manifests as avoidance, which encompasses any action or series of actions undertaken by an individual to evade or anticipate unpleasant or distressing situations, stimuli, or events, including conditioned aversive stimuli [6]. Avoidance serves as an adaptive response aimed at enhancing survival [7]. However, when the stimuli being avoided are benign or when avoidance becomes excessive, hindering daily functioning, it becomes maladaptive [8; 9]. The presence of excessive avoidance is closely linked to the development [e.g., 10] and the continuity [e.g., 11] of maladaptive anxiety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother hallmark of maladaptive anxiety concerns dysfunctional cognitions. According to the cognitive models utilized in cognitive-behavioral therapy (CBT), cognitive processes play a pivotal role in shaping behavioral and emotional reactions. Adults experiencing heightened levels of anxiety often exhibit a tendency to overestimate the likelihood of encountering threatening situations, while concurrently underestimating their own capacity to navigate and cope with such circumstances [12]. Various studies indicate the presence of comparable cognitive processes in children [2].\u003c/p\u003e\n\u003cp\u003eTo disrupt the cycle of anxiety, avoidance, and dysfunctional cognitions, it is crucial to address elevated anxiety levels in children promptly and effectively. CBT stands out as the primary treatment for AD\u0026rsquo;s in youth [13]. A review spanning five decades of CBT for youth AD\u0026rsquo;s demonstrated substantial improvements from pre- to post-treatment, with around 65% becoming free of their primary AD after CBT [14; 15]. Despite the overall efficacy of CBT in treating childhood AD\u0026rsquo;s, implementation challenges, such as limited access to trained therapists, high costs, and stigma associated with seeking mental health treatment, result in many children not receiving this treatment [16]. To address these barriers, delivering CBT through low-level online formats could be a promising solution, potentially increasing accessibility, reducing costs, and offering flexible scheduling options [17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCBT typically incorporates exposure and cognitive restructuring, involving facing anxiety-inducing situations and replacing unhelpful thoughts with functional ones, respectively. Despite CBT\u0026apos;s well-established efficacy, there is limited understanding of its specific elements contributing to effectiveness. Creswell [2] notes a lack of examination regarding the link between CBT program activities and treatment outcomes, and emphasized the need for dismantling studies. The current study aims to contribute to this gap by examining the individual components of a comprehensive online CBT intervention. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, the exposure component for children is based on the inhibitory learning theory (ILT) instead of on habituation-based models. Child exposure therapy traditionally adheres to habituation principles, aiming to gradually diminish fear responses. In habituation-based exposure, a hierarchical approach is typically used, where children rank feared scenarios, systematically progressing from least to most feared. Moreover, the child would stay in the feared scenario until their fear has diminished [18]. Despite anxiety reduction, direct evidence supporting the tenability of the habituation model is mixed [19]. An alternative approach to exposure is the inhibitory learning account. Unlike habituation-based exposure, an inhibitory learning approach does not explicitly target anxiety reduction. It involves acquiring an additional inhibitory association that counteracts on the original excitatory fear association. Effective inhibitory learning involves challenging the child\u0026apos;s expectations of the feared situation, emphasizing variability over predictable progression. Deliberately employing diverse stimuli, durations, intensities, and anxiety levels, inhibitory learning-based exposure stands out. Notably, studies that specifically incorporate variability to optimize inhibitory learning opportunities are scarce [20; 21; 22].\u003c/p\u003e\n\u003cp\u003eThe present study examines the effectivity of an online CBT intervention \u0026quot;Learn to Dare!\u0026quot; [23], targeting children and adolescents with maladaptive anxiety using a randomized controlled trial (RCT) design that compared an intervention group with a waitlist control group (WL). Our study aimed to investigate to what extent the intervention is effective in reducing maladaptive anxiety in children and adolescents. We expected a more pronounced reduction in anxiety, avoidance and negative cognition levels among participants compared to those in the WL. In addition, we explored the unique contribution of psycho-education, exposure and cognitive restructuring on child anxiety in order to contribute to the dismantling of CBT for child anxiety.\u0026nbsp;\u003c/p\u003e"},{"header":"2.1 METHOD","content":"\u003ch2\u003e2.2. Design\u003c/h2\u003e\n\u003cp\u003eThe study design was a randomized two-group (intervention versus WL) factorial design with repeated measures of the dependent variables. The assessments included a screening procedure, assessments before and after each of the intervention components (i.e., psycho-education, exposure and cognitive restructuring), as well as a three month follow-up. A detailed study design, procedure and analysis plan was described in a protocol paper [23] and were preregistered at https://osf.io/g2avh. In addition, all data and materials of this study were made publicly accessible at osf.io/d8c4p.\u003c/p\u003e\n\u003ch2\u003e2.3 Participants\u003c/h2\u003e\n\u003cp\u003eWe aimed at recruiting 8-13 year old children, who exhibited high levels of anxiety, specific phobias or other mild AD\u0026rsquo;s that are included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5, 24]. Substantial interference of major AD\u0026rsquo;s was the only exclusion criterion. We recruited our participants via the community (i.e., non-clinical/ non-referred) in the Netherlands. Figure 1 depicts the flow of participants over the course of the project from enrollment onwards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the METC azM/UM, METC173019, and was registered as a clinical trial at CCMO, NL 60801.068.17 (date: 05-16-2025). In line with ethical guidelines, participants were free to stop their participation at any time without having to provide a reason. Information, screening, interventions, and most evaluations took place on the \u0026apos;Learn to Dare!\u0026apos; platform.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhase 1 of the study trajectory consisted of the recruitment, enrolment and randomization of participants. Recruitment of children was done through online advertisements, press releases, social media, magazine/publication features, and distribution of flyers at primary schools. Parents (and children aged 12 or older) submitted a signed informed consent form to the university, receiving account details via an automated email. Thereafter, the enrolment took place, consisting of two steps. In the first step of the selection procedure, the children filled out our screening questionnaire on the platform, the Youth Anxiety Measure for DSM-5 [YAM-5, 25], with distinct cut-offs for boys and girls to ensure gender proportionality. Non-high-anxious participants (\u003cem\u003en\u003c/em\u003e = 38) were excluded, receiving guidance to general anxiety resources for children. In the second step of the selection procedure, high-anxious children took part in a diagnostic interview, the Structured Clinical Interview for DSM-5 Disorders for Children [SCID-5-Junior, 26]. The interview screened for severe (based on interference in daily life) AD\u0026rsquo;s requiring referral to professional mental healthcare. Consecutively, the high-anxious children were randomized to the intervention or WL. Importantly, all authors remained blind for randomization status of participants during all stages. We applied block randomization with the child\u0026apos;s age and sex as strata.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhase 2 of the study trajectory consisted of the intervention and the assessments. Both groups underwent identical assessments: pretest (before the intervention group received psycho-education), pre-exposure test (before the intervention group received exposure and after they received psycho-education); pre-restructuring test (before the intervention group received cognitive restructuring and after they received exposure), posttest (after the intervention), and a 3-month follow-up. At all assessment points child anxiety, avoidance behavior, and positive and negative cognitions were measured. At pretest and follow-up, children took part in the diagnostic interview. The WL had the opportunity to engage in the intervention after the final assessment. Participants discontinuing the intervention were given the option to complete assessments voluntarily.\u003c/p\u003e\n\u003ch2\u003e2.5 Intervention\u003c/h2\u003e\n\u003cp\u003eThe online CBT-based program, titled \u0026apos;Learn to Dare!,\u0026apos; addressed maladaptive child anxiety by targeting avoidance behavior and dysfunctional cognitions. The intervention took place on an online platform, and allowed for independent engagement of the children on an individual basis, irrespective of time and location. The child maintained a personalized online workbook, accessible only to the trainer, who controlled the progression of the intervention by releasing new intervention components. The intervention started with an introductory message exchange between the trainer and the participant, followed by psycho-education in session 1. Aligned with ILT, the exposure sessions (2 to 5) preceded the cognitive restructuring sessions (6 and 7). Exposure was set up in line with the ILT. The intervention concluded with relapse prevention and a farewell session (8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore the intervention, the trainer selected two anxiety domains to target. Selection was based on SCID-Junior data, prioritizing DSM-5 diagnoses of specific phobias. If no specific phobia was present, other AD classifications were considered. When no DSM-5 diagnosis was available, YAM-5 data guided the selection, again giving preference to specific phobias. The two selected anxiety domains were then randomly assigned within the platform: one to be treated with exposure, the other with cognitive restructuring.\u003c/p\u003e\n\u003cp\u003eAdherence was fostered through parental and trainer encouragement, with trainers receiving instructions and supervision from the primary author (participants remained blinded). Parents were briefed on the intervention\u0026apos;s content and tasked with encouraging their child\u0026apos;s progress. Each child received guidance from a personal trainer, holding a bachelor\u0026apos;s degree in psychology. The trainers adhered to a detailed protocol and communicated with a child through private messaging. Privacy safeguards prevented access by interviewers or other researchers to the child\u0026apos;s workbook.\u003c/p\u003e\n\u003ch2\u003e2.6 Measurements\u003c/h2\u003e\n\u003cp\u003eThe measurement tools included questionnaires and an interview. The questionnaires were embedded in the online \u0026lsquo;Learn to Dare!\u0026rsquo; platform. The diagnostic interview was performed by telephone by interviewers who were blinded for randomization status.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e2.6.1 Anxiety diagnoses\u003c/h3\u003e\n\u003cp\u003eThe examination of prevalent DSM-5 disorders in childhood was conducted using the anxiety module of the SCID-5-Junior [26]. Children and their parents were interviewed separately by trained interviewers, which took approximately 20 minutes per interview. Interviewers reviewed the DSM-5 criteria for the presence of each AD. Initial findings on the tool\u0026rsquo;s psychometric qualities indicate satisfactory agreement between parent and child reports, as well as solid convergent validity [26].\u003c/p\u003e\n\u003ch3\u003e2.6.2 Anxiety level\u003c/h3\u003e\n\u003cp\u003eThe assessment of child anxiety levels was done with the self-report version of the Youth Anxiety Measure for DSM-5 [YAM-5, 25], available at anxietymeasure.com. The YAM-5, designed for children aged 8\u0026ndash;18 years, consisted of two parts. The initial section (28 items) addressed all major DSM-5 AD\u0026rsquo;s (e.g., the fear of going anywhere without parents), while the second segment (22 items) focused on specific phobias (e.g., fear of people dressed up in costumes). Participants rated items on a 4-point scale, ranging from 0 (never) to 3 (always). Earlier studies [e.g., 27] reported good internal consistencies, test-retest reliability, concurrent validity, and construct validity for the YAM-5. The internal consistency at pretest in the current study was: Cronbach\u0026rsquo;s \u0026alpha; = 0.93, McDonald\u0026rsquo;s \u0026omega; = 0.93.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e2.6.3 Avoidance\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eTo examine avoidance related to anxiety, fear or worry in children, we utilized the Child Avoidance Measure Self report [CAMS, 28]. The CAMS consisted of eight items that were preceded by a general stem statement: \u0026ldquo;When I feel scared or worried about something \u0026hellip;\u0026rdquo;. The items measure passive avoidance (e.g., \u0026ldquo;...I try not to go near it/avoid it\u0026rdquo;), active avoidance (e.g., \u0026ldquo;\u0026hellip;I feel scared until I get away from it\u0026rdquo;), and refusal (e.g., \u0026ldquo;\u0026hellip;I refuse to do it\u0026rdquo;), The items were scored on a 4-point scale (0 = \u0026ldquo;almost never\u0026rdquo; to 3 = \u0026ldquo;almost always\u0026rdquo;). The CAMS was translated and back-translated into Dutch. A recent study on the Dutch CAMS [29] confirmed the original CAMS\u0026rsquo; sound psychometric properties. The internal consistency at pretest in the current study was: Cronbach\u0026rsquo;s \u0026alpha; = 0.76, McDonald\u0026rsquo;s \u0026omega; = 0.79.\u003c/p\u003e\n\u003ch3\u003e2.6.4 Negative and positive cognitions\u003c/h3\u003e\n\u003cp\u003eChildren\u0026apos;s automatic negative and positive cognitions were evaluated using the Dutch version of the Children\u0026rsquo;s Automatic Thoughts Scale-Negative/Positive [CATS-N/P, 30]. Responses for all items are recorded on a 5-point scale, ranging from 0 (not at all) to 4 (all the time). Higher sum scores on Physical Threat, Social Threat, and Personal Failure indicated more negative cognitions; higher scores on Positive Cognitions indicated more positive cognitions. Hoogendoorn and colleagues [30] established robust psychometric properties for the CATS-N/P, reporting Cronbach\u0026apos;s alpha values between .90 and .96 for the overall score. The internal consistencies in the current study for negative and positive cognitions respectively were Cronbach\u0026rsquo;s \u0026alpha; = 0.95, McDonald\u0026rsquo;s \u0026omega; = 0.95; Cronbach\u0026rsquo;s \u0026alpha; = 0.92, McDonald\u0026rsquo;s \u0026omega; = 0.92. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.7 Analyses\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Due to a sample size smaller than initially intended, our study lacked the statistical power to fully scrutinize the comprehensive original research model outlined in Simon et al. [23]. Consequently, we were unable to assess whether the intervention\u0026apos;s impact on child anxiety was mediated by reductions in avoidance behavior and dysfunctional cognitions. We performed analyses at group and at individual level. The analyses at group level were considered intention-to-treat analyses and were applied on imputed data till posttest. There were too many dropouts at the follow-up assessment, making any imputation method invalid. The analyses at the individual level were applied on complete data till posttest, and if data were also present of the follow-up assessment, we also included these data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData preparation involved the following steps. First, missing data were imputed. For the analyses at the group level, we applied two imputation methods: 1) imputing the data from the previous assessment point; 2)imputing the mean between two assessment points. We reported the outcomes of the data where missing values were imputed by method 1, and mentioned whether the other imputation method yielded different results. We labelled the children who completed the assessments including posttest \u0026lsquo;completers\u0026rsquo; (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 35). Second, outliers were winsorized to maximum values of \u003cem\u003eM\u003c/em\u003e + - 3\u003cem\u003eSD\u003c/em\u003e. Third, the pretest data were checked for normality (skewness and kurtosis + - 1.5) after the outliers were removed. We applied non-parametric variants of the analytic tests if assumptions of normality were violated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analyses at the group level were performed with a clinical dichotomous outcome measure (i.e.: diagnosis present versus diagnosis not present) as well as with continuous data (i.e., level of anxiety, avoidance, negative cognitions, positive cognitions). Chi-squared tests were applied to examine whether groups differed on frequency of the clinical dichotomous outcome measure diagnosis present versus diagnosis not present. In addition, we performed GLM repeated measures ANOVA consecutively with level of anxiety of major AD\u0026rsquo;s, level of anxiety of specific phobias, total level of anxiety, avoidance, negative cognitions and positive cognitions at the different time points (pre-, post-, and follow-up assessment) as within-subject factors and group (intervention group versus WL) as between-subjects-factor. In case the assumption of sphericity was violated, we applied a Greenhouse-Geisser correction. Partial eta squared were used as effect sizes, where small effects are indicated by an \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u0026nbsp;\u003c/sub\u003e\u003c/em\u003eof approximately .01, medium effects by an\u003cem\u003e\u0026nbsp;\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u0026nbsp;\u003c/sub\u003e\u003c/em\u003eof approximately .06 and large effects of \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u0026nbsp;\u003c/sub\u003e\u003c/em\u003eof approximately .14 [31]. We applied a .05 significance level and used Jamovi to perform these analyses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the analyses at the individual level, we adopted an alternative, the Reliable Change Indices (RCI, 32; 33; 34], to assess the effectiveness of these interventions. Unlike standard pre-post treatment evaluations, this approach not only measures the statistical significance of \u0026ldquo;changes\u0026rdquo;, but also evaluates their clinical relevance. By offering a more precise indication of clinical changes, it supports health providers in making individualized decisions [35]. Considering the significant variability in symptoms and progression, applying and assessing interventions on an individualized basis appeared to be a suitable approach. An individual\u0026rsquo;s change was considered a clinically significant positive change if RCI \u0026gt; 1.96 and a clinically significant negative change if RCI \u0026lt; -1.96. We used Microsoft Windows Excel to perform these analyses. \u0026nbsp;\u003c/p\u003e"},{"header":"3.1 RESULTS","content":"\u003ch3\u003e\u003cstrong\u003e3.2 Descriptives\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe participating children (\u003cem\u003en\u003c/em\u003e = 92) had a mean age of 9.77 (\u003cem\u003eSD\u003c/em\u003e = 1.55). The sample consisted of 42 boys (46%) and 50 girls (54%). Regarding diagnostic information, there were 54 children (59%) with one or more DSM-5 AD\u0026rsquo;s at pretest. The three most commonly diagnosed AD\u0026rsquo;s at pretest were: specific phobia (\u003cem\u003en\u003c/em\u003e = 36, 39%), \u0026nbsp;generalized AD (\u003cem\u003en\u003c/em\u003e = 19, 21%), and social AD (\u003cem\u003en\u003c/em\u003e = 12, 13%). We checked whether the groups were comparable at the pretest. There were no differences on demographic features, presence of AD\u0026rsquo;s, type of AD\u0026rsquo;s, level of anxiety, negative cognitions, positive cognitions, nor on the presence or type of AD\u0026rsquo;s between children who were randomized to the intervention group and those randomized to the WL, all \u003cem\u003ep\u003c/em\u003e\u0026rsquo;s \u0026gt; .10. However, it appeared that children in the intervention group had significantly lower avoidance scores at pretest than children in the WL, Mann-Whitney \u003cem\u003eU\u003c/em\u003e = 641, \u003cem\u003ep\u003c/em\u003e = .004. When checking for differences between boys and girls at pretest, we found that separation AD was diagnosed more frequently in girls (\u003cem\u003en\u003c/em\u003e = 8, 16%) than in boys (\u003cem\u003en\u003c/em\u003e = 1, 2%), \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e(1) = 4.80, \u003cem\u003ep\u003c/em\u003e = .036. There were no other pretest differences between boys and girls, all \u003cem\u003ep\u003c/em\u003e\u0026rsquo;s \u0026gt; .10. The descriptive statistics of anxiety level, avoidance and positive and negative cognitions are shown in Table 1 and the pretest correlations between these variables are depicted in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDevelopment of Anxiety\u003csup\u003ea\u003c/sup\u003e, Avoidance\u003csup\u003eb\u003c/sup\u003e, Negative and Positive Cognitions\u003csup\u003ec\u003c/sup\u003e of Waitlist Control Group (n = 31) and Intervention Group (n = 61)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"886\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eBefore exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eBefore cognitive restructuring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePosttest\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eWaitlist\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eWaitlist\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eWaitlist\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eWaitlist\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eLevel of anxiety\u003c/p\u003e\n \u003cp\u003eMajor anxiety disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e29.70 (16.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.90 (12.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e28.80\u003c/p\u003e\n \u003cp\u003e(15.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.10 (11.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.70 (16.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e23.40 (11.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.10 (15.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e22.80 (12.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eLevel of anxiety\u003c/p\u003e\n \u003cp\u003eSpecific phobias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e22.30 (10.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18.60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(9.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e23.30 (11.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.80 (10.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e22.10 (11.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.80 (10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e21.70 (11.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.20 (10.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eTotal level of anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e51.30 (23.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e44.50 (18.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e51.90 (25.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e42.70 (19.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e47.40 (25.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e41.30 (18.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e46.60 (25.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e40.00 (20.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eAvoidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e13.90\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(5.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e9.95\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(7.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e7.52\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(6.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e6.48\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(7.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11.50\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(7.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e6.83\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(7.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e12.30\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(6.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e14.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(4.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eNegative cognitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e28.80 (20.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e22.80 (16.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e27.80 (21.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e19.40 (16.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25.50 (21.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18.60 (16.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e23.10 (20.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e18.00 (16.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003ePositive cognitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e16.70 (10.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(9.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e16.30 (10.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.00\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(9.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.30 (11.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e17.40\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(9.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e16.80 (10.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e16.60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(8.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e \u003csup\u003ea\u003c/sup\u003eMeasured with the YAM-5, \u003csup\u003eb\u003c/sup\u003emeasured with the CAMS, \u003csup\u003ec\u003c/sup\u003emeasured with the CATS-N/P.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eTable 2\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003ePretest correlations between major anxiety disorders\u0026rsquo; anxiety level (MAD), specific phobias\u0026rsquo; anxiety level (SP), total anxiety level, avoidance, and positive and negative cognitions\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eMAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eSP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eTotal level of anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eAvoidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eNegative cognitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003ePositive conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.62\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTotal anxiety level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.92\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.87\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAvoidance \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNegative cognitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.74\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.52\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.72\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePositive cognitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e-.36\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Note. \u003csup\u003e***\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e\n\u003ch2\u003e3.3 Evaluation of the intervention\u003c/h2\u003e\n\u003cp\u003eAt the posttest, 19 children who participated in the intervention were asked about how they experienced the intervention. The results of this evaluation are depicted in Table 3. Additionally, there were twelve children who voluntarily reported their reason for ending their participation in the intervention. Their answers could be categorized as follows: child disliked the intervention: \u003cem\u003en\u003c/em\u003e = 4 (33%); child made enough progress: \u003cem\u003en\u003c/em\u003e = 3 (25%); child was not motivated anymore: \u003cem\u003en\u0026nbsp;\u003c/em\u003e= 3 (25%); child thought the training was not suitable for his/her fears: \u003cem\u003en\u0026nbsp;\u003c/em\u003e= 1 (8%); child disliked completing the questionnaires that were part of the larger study: \u003cem\u003en\u0026nbsp;\u003c/em\u003e= 1 (8%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChildren\u0026rsquo;s (n = 19) Evaluation of the Intervention (grades: 1: extremely bad; 10 extremely good)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat grade do you give to\u0026hellip;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade (1-10)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eM, SD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u0026hellip;the entire intervention)?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8.21 (1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u0026hellip;your trainer?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9.16 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u0026hellip;the difficulty of the intervention?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e5.37 (2.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u0026hellip;the exposure sessions?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.45 (1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 491px;\"\u003e\n \u003cp\u003e\u0026hellip;the cognitive restructuring sessions?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6.71 (2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e3.4 Effectiveness of the intervention\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWith respect to diagnostic data, we examined whether the intervention and WL differed on the presence of AD\u0026rsquo;s at post-test. Whereas the groups did not differ on the presence of AD\u0026rsquo;s, nor on the type of AD\u0026rsquo;s, both \u003cem\u003ep\u003c/em\u003e\u0026rsquo;s \u0026gt; .10, we found there were less classifications of social phobia at posttest in the intervention than in the WL, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e(1) = 10, \u003cem\u003ep\u003c/em\u003e = .002, and less classifications of generalized AD, \u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e(1) = 10, \u003cem\u003ep\u003c/em\u003e = .002. No other differences regarding the presence of AD\u0026rsquo;s were present between the groups, all \u003cem\u003ep\u003c/em\u003e\u0026rsquo;s \u0026gt; .10.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the other clinical outcome measures, we compared the development of anxiety levels, avoidance and negative and positive cognitions in intervention and WL children. The intention-to-treat-analyses showed the following outcomes. The major AD\u0026rsquo;s anxiety level decreased significantly over time, \u003cem\u003eF\u003c/em\u003e(2.33) = 12.98, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep\u003c/sub\u003e\u003c/em\u003e = .13, but there was no significant difference between groups over time, \u003cem\u003eF\u003c/em\u003e(2.33) = .66, \u003cem\u003ep\u003c/em\u003e = .54, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .01. The specific phobias\u0026rsquo; anxiety level did not decrease significantly over time, \u003cem\u003eF\u003c/em\u003e(2.20) = 1.46, \u003cem\u003ep\u003c/em\u003e = .23, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .02, and the groups did not differ in their course over time, \u003cem\u003eF\u003c/em\u003e(2.20) = 1.09, \u003cem\u003ep\u003c/em\u003e = .34, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .01. The total level of anxiety decreased significantly over time, \u003cem\u003eF\u003c/em\u003e(3) = 8.75, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= = .09, but there was no significant difference between groups over time, \u003cem\u003eF\u003c/em\u003e(3) = .70, \u003cem\u003ep\u003c/em\u003e = .55, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .01. Avoidance changed significantly over time, \u003cem\u003eF\u003c/em\u003e(3) = 20.48, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .19. and the groups differed significantly in their course over time, \u003cem\u003eF\u003c/em\u003e(3) = 5.86, \u003cem\u003ep\u003c/em\u003e \u0026lt; .01, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .06. Post-hoc tests showed a significant increase in avoidance in the intervention group after the intervention group received cognitive restructuring, \u003cem\u003et\u003c/em\u003e(59) = 629, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e = .81, while avoidance in the WL did not increase significantly after this assessment point, \u003cem\u003eW\u003c/em\u003e(30) = 21, \u003cem\u003ep\u003c/em\u003e = .54. Negative cognitions decreased significantly over time, \u003cem\u003eF\u003c/em\u003e(3) = 10.32, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .11, but the groups did not differ in their course over time, \u003cem\u003eF\u003c/em\u003e(3) = .06, \u003cem\u003ep\u003c/em\u003e = .64, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .01. Positive cognitions did not change significantly over time, \u003cem\u003eF\u003c/em\u003e(3) = .52, \u003cem\u003ep\u003c/em\u003e = .67, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .01, and groups did not differ in their course over time, \u003cem\u003eF\u003c/em\u003e(3) = .10, \u003cem\u003ep\u003c/em\u003e = .96, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= = .001. The results were comparable when the other imputation method was applied, except for avoidance. That is, when missing values were imputed with the mean between time points, avoidance did decrease significantly over time, \u003cem\u003eF\u003c/em\u003e(2.50) = 7.93, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .12, but the courses of avoidance did not differ significantly between groups, \u003cem\u003eF\u003c/em\u003e(2.50) = 1.6, \u003cem\u003ep\u003c/em\u003e = .32, \u003cem\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003csub\u003ep \u0026nbsp;\u003c/sub\u003e\u003c/em\u003e= .02.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin the group of completers, we also examined the effectiveness of the intervention by calculating RCI\u0026rsquo;s for anxiety level, avoidance and negative as well as positive cognitions. First, we checked whether completers differed from drop-outs on anxiety level, avoidance, negative and positive cognitions at pretest. It appeared that completers had significantly lower anxiety levels (\u003cem\u003eM\u003c/em\u003e = 41.3, \u003cem\u003eSD\u003c/em\u003e = 18.27) than drop-outs (\u003cem\u003eM\u0026nbsp;\u003c/em\u003e= 50.1, \u003cem\u003eSD\u003c/em\u003e = 21.2) at pretest, \u003cem\u003et\u003c/em\u003e(87) = 2.01, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .047, and completers had significantly lower negative cognitions at pretest (\u003cem\u003eM\u003c/em\u003e = 18.6, \u003cem\u003eSD\u003c/em\u003e = 13.14), than drop-outs (\u003cem\u003eM\u003c/em\u003e = 28.9, \u003cem\u003eSD\u003c/em\u003e = 20.72), Mann-Whitney \u003cem\u003eU\u003c/em\u003e = 561, \u003cem\u003ep\u003c/em\u003e = .013. No other differences between completers and drop-outs were found, all \u003cem\u003ep\u0026rsquo;\u003c/em\u003es \u0026gt; .05.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith respect to the effectiveness of the intervention in the group of completers, it was found that more children of the intervention group made a clinically significant improvement on child anxiety level, 33% (\u003cem\u003en\u003c/em\u003e = 8) than children of the WL, 18% (\u003cem\u003en\u003c/em\u003e = 2), whereas 8% (\u003cem\u003en\u003c/em\u003e = 2) of the children of the intervention group deteriorated clinically significantly versus 0% of the children of the WL. The Jacobson-Truax plot (Figure 2) depicts the RCI\u0026rsquo;s of child anxiety of the intervention and the WL groups. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding avoidance, 0% of the children in both groups made a clinically significant improvement, whereas 5% (\u003cem\u003en\u003c/em\u003e = 1) of the children of the intervention deteriorated clinically significantly versus 0% of the children of the WL. With regard to negative cognitions, 21% (\u003cem\u003en\u003c/em\u003e = 5) of the children of the intervention group made a clinically significant improvement and 22% (\u003cem\u003en\u003c/em\u003e = 2) of the children of the WL, whereas 4% (\u003cem\u003en\u003c/em\u003e = 1) of the children of the intervention group deteriorated clinically significant versus 0% of the children of the WL. With respect to positive cognitions, 4% (\u003cem\u003en\u003c/em\u003e = 1) of the intervention group and 0% of the WL made a clinically significant improvement, whereas 22% (\u003cem\u003en\u003c/em\u003e = 5) of the intervention group and 22% (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 2) of the WL deteriorated clinically significantly.\u003c/p\u003e"},{"header":"4.1 DISCUSSION","content":"\u003cp\u003eThis study evaluated the effectiveness of the online CBT-based intervention \u0026lsquo;Learn to Dare!\u0026rsquo; in reducing maladaptive anxiety in children and adolescents using a randomized controlled trial with a WL condition. We hypothesized that participants in the \u0026quot;Learn to Dare!\u0026quot; intervention would show greater reductions in anxiety diagnoses and anxiety, avoidance and negative cognition levels compared to the WL. Children in the intervention group were significantly less likely to meet diagnostic criteria for social AD and generalized AD than children in the WL at follow-up. No group differences were found for other AD\u0026rsquo;s at follow-up. Anxiety level, avoidance and negative cognitions declined equally in both groups, whereas positive cognitions were not affected by time nor by intervention. However, when examining children who completed all assessments, a higher proportion of children in the intervention group made a clinically significant improvement on anxiety level. In sum, these findings offer partial support for our hypothesis. Specifically, we observed a reduction in diagnoses of social anxiety disorder (SAD) and generalized anxiety disorder (GAD) within the intervention group, and favorable outcomes were particularly evident among children who completed the full program.\u003c/p\u003e\n\u003cp\u003eIn contrast to the online version of Learn to Dare!, the face-to-face version [36] was found to be consistently effective across different types of anxiety diagnoses, with more robust and uniform outcomes. The face-to-face version of \u0026lsquo;Learn to Dare!\u0026rsquo; differed from the online version of \u0026lsquo;Learn to Dare!\u0026rsquo; in how it was delivered in three ways: the face-to-face version was offered in group format, it did not contain online elements, and exposure adhered to habituation. With respect to offering CBT for child anxiety individually or in group format, meta-analyses [13; 37] reveal no differences in effectiveness. We, therefore, argue that the unique findings of the online version of \u0026lsquo;Learn to Dare!\u0026rsquo; may be attributed to its online character and/or to the fact that exposure was provided in line with the inhibitory learning theory (ILT).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the online character of the current intervention, meta-analyses [e.g., 38] show that online interventions for child anxiety are generally effective in the short term. For social AD, Nordh et al. [39] found that online CBT not only reduced symptoms but was also cost-effective. However, long-term effects remain unclear [40], and many youths prefer face-to-face treatment [41; 42]. More research is needed to determine which delivery format suits whom. Comparing online, face-to-face, and blended CBT formats is also relevant. Blended care, combining in-person and digital elements, has proven more effective than online intervention in adults [43] and is seen as optimal for depressed children [44], though evidence for anxious children is still limited [45].\u003c/p\u003e\n\u003cp\u003eWith respect to offering exposure in ILT format, this study represents a novel contribution to the field. ILT posits that the efficacy of exposure is primarily driven by expectancy violation, whereby individuals are encouraged to articulate their core fearful expectation, and then engage in exposure exercises designed to maximally disconfirm these expectations. Although the intervention as a whole was found to be beneficial on certain outcome measures, findings did not reveal a specific positive or negative contribution of exposure on child anxiety, avoidance or positive and negative cognitions. Despite our attempts to facilitate the exposure process by introducing a video-model, a playful metaphor and support by the trainer, a critical observation during the study was the difficulty a substantial number of children experienced in verbalizing their fearful expectations. This observation raises important questions about the developmental appropriateness and practical feasibility of ILT-based exposure in younger populations. Furthermore, the ILT-based exposure protocol may have posed greater challenges compared to traditional habituation-based approaches. Key elements, such as the discouragement of safety behaviors, and the use of a variable rather than a hierarchical approach, may have contributed to participants\u0026rsquo; perceived difficulty of the intervention and the high attrition rates observed. These challenges were potentially exacerbated by the online, self-guided format of the intervention, which may have been particularly demanding for high-anxious 8-13 year olds. Future research is warranted to further investigate the suitability of ILT-based exposure for pediatric populations and when using online formats.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the online intervention showed positive effects for some children, a small number experienced clinically significant deterioration, particularly in avoidance and positive cognitions. These findings are consistent with previous research indicating that psychotherapy can have adverse effects in a minority of cases [46]. This highlights the importance of monitoring negative outcomes, especially in online formats.\u003c/p\u003e\n\u003cp\u003eAs outlined in our protocol paper [23], we initially aimed to conduct a dismantling study. However, due to the limited sample sizes, we were only able to explore\u0026mdash;rather than isolate\u0026mdash;the contributions of psychoeducation, exposure, and cognitive restructuring. Avoidance increased following cognitive restructuring, which aligns with findings by Stiede et al. [47], who argue that cognitive techniques may slow learning, and by Whiteside et al. [48], who suggest that strategies like positive distraction and thought stopping can reinforce avoidance. No specific effects of the individual components were found on other outcome measures. Notably, children who completed the intervention showed clinical improvements in anxiety level, unlike those who dropped out\u0026mdash;suggesting that the combination of psychoeducation, exposure, and cognitive restructuring may have a synergistic effect.\u003c/p\u003e\n\u003cp\u003eGiven the considerable efforts we made to promote participant enrollment in the intervention and to minimize dropout, we consider the high attrition rate in this study as a side effect of the study/intervention rather than a limitation. Therefore, we inspected the attrition rates throughout the study, examined features of children who dropped out and evaluated the voluntary feedback from drop-outs. We identified several interesting findings that may be related to the high attrition observed in this online CBT for child anxiety. First, 60% of the participants who initially showed interest in the study choose not to participate in the study after receiving the voluminous informed consent packages. Although awareness of the importance of clinical trials in children has grown within both the scientific community and the general public, conducting such trials remains difficult. This is largely due to the more complex and stringent requirements for obtaining consent in children compared to adults [49]. The participation rate of children in scientific research could be improved if medical ethics review boards were to permit and promote more patient-friendly communication. Second, it appeared that children who completed the online intervention had lower levels of anxiety and negative cognitions before the start of the intervention than children who dropped-out. This is in line with previous research indicating higher acceptability of online treatment for people with mild to moderate symptoms than for people with severe symptoms [50]. This could indicate that online CBT-interventions, such as \u0026lsquo;Learn to Dare!\u0026rsquo; may be specifically appropriate as waitlist intervention, or for prevention and early intervention purposes. Third, although the intervention was generally well-liked, children who dropped out most often cited a dislike of the intervention. Since online interventions for child anxiety remain a promising avenue to increase the number of anxious children receiving help, it is of essence to enhance user engagement and facilitate the adoption of internet-based treatments. Future research can investigate the effect of adding game-like features to the online format, such as in-game rewards and badges, which may increase the appeal of the intervention and treatment engagement [51]. In addition, future developers of online interventions are encouraged to engage intended end users in the development process through user-centered design and usability testing [52].\u003c/p\u003e\n\u003cp\u003eOne way to understand the results of our study and the high attrition rate is to consider the paradigmatic assumptions underlying our research design. A common assumption in psychotherapy research has been that change is gradual and linear, yet emerging evidence suggests that psychological change often follows nonlinear, dynamic patterns [53]. Our study design reflects the linear assumption through predetermined measurement intervals and the expectation of predictable intervention effects. From a dynamic systems perspective, participants are not passive recipients but actively shape their own development and utilize the intervention as a resource for their own goals [54]. This may explain why some children discontinued the intervention: not due to passive \u0026quot;dropout,\u0026quot; but due to an active decision that the intervention did not align with their own change process. These insights call for a fundamental reconsideration of how we design intervention studies. As Deisenhofer et al. [55] argue, implementing precision methods requires moving beyond traditional assumptions about homogeneous treatment responses, understanding change as a complex, self-organizing process rather than as a linear consequence of our interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study should be interpreted in light of its limitations. First, we originally aimed to conduct a dismantling study with multiple assessments and outcomes, but small sample sizes limited us to an exploratory analysis of the CBT components. The fact that dismantling requires large-scale new studies to be carried out [56], appears to impede the conduct of such studies. Indeed, experimental dismantling studies on CBT for child anxiety have rarely been performed [see reviews: 57; 48], despite repeated calls for this type of study [e.g., 14]. Second, we used Reliable Change Indexes (RCIs) as an alternative to the original analytical approach. While this allowed for an exploratory look at individual-level change, we acknowledge that RCIs have notable limitations. Critics highlight their low sensitivity to real change, reliance on only two time points, and potential for misinterpretation\u0026mdash;especially when reliability estimates are suboptimal [58]. Although the RCI offered a practical solution in our context, future research would benefit from more robust longitudinal methods where possible, such as latent change score models or multilevel growth models [59; 60]. Third, while some children who dropped out shared their reasons, the information is limited. Most cited a general dislike of the intervention, but the specific reasons for this dislike remain unclear. This lack of detailed feedback hinders our ability to improve the training to reduce dropout and limits its value for future research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Clinical implications\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e The findings suggest that the online version of \u0026lsquo;Learn to Dare!\u0026rsquo; may be a valuable option for children with milder anxiety and less negative cognitions (e.g., during waitlist periods), or for children with social AD or generalized AD. For these groups, the accessible and self-guided nature of the intervention may be sufficient to achieve meaningful improvements. In contrast, children with more severe anxiety may benefit from the real-time guidance and support of a therapist, especially during exposure. Depending on symptom severity and individual needs, face-to-face or blended interventions for child anxiety may offer additional advantages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Conclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn conclusion, the current study provides partial support for the effectiveness of the online CBT-based intervention \u0026quot;Learn to Dare!\u0026quot; in reducing maladaptive anxiety among children and adolescents. That is, the intervention group showed significantly better outcomes for anxiety levels among children who completed all assessments, and for social and generalized AD\u0026rsquo;s at follow-up.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eHuman Ethics and Consent to Participate Declaration\u003c/h2\u003e \u003cp\u003e This study was reviewed and approved by the METC azM/UM, METC173019, and was registered as a clinical trial via CCMO, NL 60801.068.17. Written informed consent was obtained from the legal guardians of all participating children prior to participation. Children aged 12 years and older also provided written informed consent prior to participation. All procedures were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003cb\u003eFunding Declaration\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study was funded by Mind Netherlands (grant number 2015 7025), Stationsplein 125, 3818 LE Amersfoort, The Netherlands. The funding body approved the study design but had no role in the collection, analysis, or interpretation of the data, nor in the writing of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEllin Simon wrote the main manuscript text and performed the main analysesSara Scheveneels wrote parts of the discussion and reviewed the manuscriptPeter Verboon performed a simulated power analyses, and worked conjointly with the first author on the analysesEva de Hullu wrote parts of the discussion and reviewed the manuscriptSusan van Hooren reviewed the manuscript and supervised the proces.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eIn addition, all data and materials of this study were made publicly accessible at osf.io/d8c4p.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePolanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. 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Acceptability of internet treatment of anxiety and depression. Australas Psychiatry. 2011;19(3):259\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristie GI, Shepherd M, Merry SN, Hopkins S, Knightly S, Stasiak K. Gamifying CBT to deliver emotional health treatment to young people on smartphones. Internet Interv. 2019;18:100286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill C, Reardon T, Taylor L, Creswell C. Online support and intervention for child anxiety (OSI): development and usability testing. JMIR Form Res. 2022;6(4):e29846.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes AM, Laurenceau JP, Feldman G, Strauss JL, Cardaciotto L. Change is not always linear: the study of nonlinear and discontinuous patterns of change in psychotherapy. Clin Psychol Rev. 2007;27(6):715\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffiths R, Huddy V, Eaton S, Waldorf J, Mansell W. Rethinking secondary mental healthcare: a perceptual control theory perspective. London: Taylor \u0026amp; Francis; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeisenhofer AK, Barkham M, Beierl ET, Schwartz B, Aafjes-van Doorn K, Beevers CG, et al. Implementing precision methods in personalizing psychological therapies: barriers and possible ways forward. Behav Res Ther. 2024;172:104443.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeijten P, Weisz JR, Gardner F. Research strategies to discern active psychological therapy components: a scoping review. Clin Psychol Sci. 2021;9(3):307\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunning EE, Khan AN, Becker-Haimes EM, Guzick AG. When attempts to help backfire: psychosocial interventions that may inadvertently prolong anxiety among youth. Res Child Adolesc Psychopathol. 2025;1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAleavey AA. 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Annu Rev Psychol. 2009;60(1):577\u0026ndash;605.\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":false,"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":"Child anxiety, Avoidance, Cognitions, Online CBT, Inhibitory learning, Attrition","lastPublishedDoi":"10.21203/rs.3.rs-7926457/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7926457/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the proven efficacy of cognitive-behavioral therapy (CBT) for childhood anxiety, most anxious children do not receive treatment due to implementation barriers. Low-intensity online formats may help address this gap. This study examined the effectiveness of the online CBT-based program \u003cem\u003eLearn to Dare!\u003c/em\u003e for children aged 8\u0026ndash;13 with maladaptive anxiety, and explored the role of its components: psychoeducation, exposure (based on inhibitory learning), and cognitive restructuring.\u003c/p\u003e \u003cp\u003eIn a randomized controlled design, 92 children (\u003cem\u003eM\u003c/em\u003e\u003csub\u003eage\u003c/sub\u003e = 9.77, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.55) were assigned to the intervention (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;61) or a waitlist control group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31). Assessments took place pre- and post-intervention, and at 3-month follow-up. Anxiety, avoidance, and negative cognitions decreased over time in both groups, while positive cognitions remained stable. A larger proportion of intervention participants showed clinically significant improvement in anxiety levels compared to controls, though not on other measures. At follow-up, children in the intervention group were significantly less likely to meet diagnostic criteria for social anxiety disorder and generalized anxiety disorder, but not for other anxiety disorders.\u003c/p\u003e \u003cp\u003eNo consistent effects were found for individual components, except for an unexpected increase in avoidance after cognitive restructuring. Also of relevance, high attrition in this online CBT for child anxiety appeared related to higher baseline anxiety levels among drop-outs and limited user engagement. In sum, the online \u003cem\u003eLearn to Dare!\u003c/em\u003e intervention appears beneficial for children with mild to moderate maladaptive anxiety who complete the intervention, and specifically those with social or generalized anxiety disorder.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Evaluation of the Online Version of ‘Learn to Dare!’, a Cognitive-behavioral Intervention for Child Anxiety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 10:04:16","doi":"10.21203/rs.3.rs-7926457/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-12T18:51:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-01T15:34:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160333749427711228961869290891524662058","date":"2026-02-03T13:43:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T15:45:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127557610841509467879508861859912243883","date":"2025-12-28T14:54:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147537435959482117925235106437939824454","date":"2025-12-26T08:43:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-26T06:34:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-10T10:46:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T13:50:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-08T13:46:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-10-22T20:04:16+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":"9e3d7c91-0d8c-4a54-8ee8-46f586f7a84e","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T11:54:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 10:04:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7926457","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7926457","identity":"rs-7926457","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}