Research spotlight: evaluating hybrid and virtual treatments for children with anxiety and obsessive-compulsive disorder

Jacqueline Sperling, PhD, a clinical psychologist and assistant professor of Psychology at Harvard Medical School, and co-program director of the McLean Anxiety Mastery Program, led a study investigating the sustainability of outcomes from an intensive group and family-based outpatient cognitive behavioral treatment (CBT) program, that included a hybrid of in-person and virtual treatment sessions for children and adolescents with anxiety disorders and/or obsessive-compulsive disorder (OCD). Her research, which was published last month in Current Developmental Disorders Reports, suggests that an intensive hybrid format may offer lasting gains even after children have finished treatment.

In addition to Sperling, other McLean authors include Abigail Stark, PhD, Esther Tung, PhD and R. Meredith Elkins, PhD. Sperling describes her team’s research and how the COVID-19 pandemic spurred this investigation into virtual components of child and adolescent mental health treatment.

What led you to explore this area of research?

Our previous research has demonstrated that intensive group and family-based outpatient CBT can yield improvements in symptoms and functional impairment for children with anxiety and OCD using either in-person or virtual formats, with no significant differences between the two. For this new study, we wanted to see whether a hybrid format of both in-person and virtual treatment sessions not only could demonstrate similar outcomes, but also could offer lasting gains months after discharge from the treatment program.

This topic especially was of interest to our group given how treatment delivery models have shifted since the COVID-19 pandemic, to include more virtual sessions.

How did you conduct the study?

Our study participants included 63 children and adolescents between ages 8 and 19, who were treated at McLean’s Anxiety Mastery Program (MAMP).

Patients at MAMP received intensive outpatient group- and family-based CBT from a care team that included a psychologist, psychiatrist and doctoral student. Prior to the COVID-19 pandemic, the program consisted of individually tailored in-person treatment for four afternoons a week, from a minimum of four weeks to an average of eight weeks. Three of the afternoons offered group-based treatment, which included treatment-review check-ins with caregivers afterward, and on one of the days, each family participated in two, weekly 45-minute sessions with a psychologist and psychiatrist. In addition to daily check-ins and participation in weekly family and psychopharmacology meetings, and caregivers attended caregiver guidance groups, one to two times per week, a frequency that changed in response to caregivers’ feedback and attendance. 

Caregivers and their children completed questionnaires at the start of treatment, the last day of treatment, and three months after treatment ended. When examining caregivers’ and children’s responses, the changes in the program’s format were accounted for in analyses.

In March 2020 when the COVID-19 pandemic unfolded, we shifted to an entirely virtual model offering telehealth-based intensive treatment. By the summer of 2022, we transitioned to a hybrid model of care, with one in-person group-based day and three virtual treatment days each week.

Caregivers and their children completed questionnaires at the start of treatment, the last day of treatment, and three months after treatment ended. The analyses focused on the families’ responses at each of those timepoints. 

What did your findings reveal?

Both caregivers and youth in the hybrid program not only reported significant improvements in children's anxiety and depression symptoms as well as functional impairment by discharge, but they also reported that the treatment gains had persisted three months after discharge.

Our results suggest that intensive outpatient group- and family-based CBT that integrates telehealth can lead to lasting improvements in pediatric anxiety and OCD symptoms beyond discharge. It is important to note that the treatment program recommended that families pursue less intensive outpatient CBT after discharge to facilitate the sustainment of treatment gains, and the majority of families reported that they did have their children continue to meet with outpatient clinicians after discharge. Therefore, this study cannot determine which factors, the intensive program and/or the subsequent outpatient treatment, contributed to the sustainment of treatment gains. It may be that both are needed so children can build upon the foundation of progress established in an intensive short-term program.

What are the implications of this work for patients and their families and physicians?

Some research has found that one-third of children or more will have an anxiety disorder before adulthood. If untreated, there can be lifelong negative impacts, such as: challenges with interpersonal relationships, increased risk for mental health and other health complications, and struggles with finances and careers. OCD has been found to affect 2-3 percent of youth and also can contribute to persisting impairment into adulthood if not treated effectively. For those reasons, treatments that provide lasting effects for children are needed significantly. 

Given the well-documented increase in rates of child and adolescent mental illnesses during the COVID-19 pandemic, an intensive, hybrid treatment format may be a way to increase access to much-needed care.