Psychiatry · Medical Literature
Internet-Based Cognitive Behavioral Therapy and Telephone Coaching for Anxiety in Children.
Abstract
Limited data are available on the long-term effectiveness of internet-based cognitive-behavioral therapy (iCBT) for anxiety among children. To evaluate the association of an iCBT intervention with anxiety in children compared with a psychoeducation control group over 12 and 24 months. This cohort study is based on 2-year follow-up data of the randomized clinical trial Master Your Worries, which was conducted between August 2017 and January 2020. Participants were Finnish school children aged 10 to 13 years identified through population-level screening as exhibiting elevated levels of anxiety. Statistical analyses for this study were performed between June 2, 2025, and June 16, 2026. Participants in the intervention group followed an internet-based therapy program, which comprised 10 modules, including telephone contact with a coach. The control group received psychoeducation in digital form. The primary outcome was change in participants' anxiety measured by the total score of the Screen for Child Anxiety Related Disorders-Child and Parent versions (SCARED-C/P). The secondary outcomes were changes in SCARED-C and SCARED-P subscale scores as well as scores on the Child Anxiety Impact Scale, Child Depression Inventory, and Depression Anxiety and Stress Scale-21 Items. A total of 465 children (median [range] age 11, [10-13] years; 332 [71%] girls) with anxiety symptoms (SCARED total score of ≥22 at baseline) were followed up for 2 years after randomization. On the basis of a linear mixed-effects model for repeated measures, the primary outcomes (SCARED-C and SCARED-P total scores) showed statistically significant differences between the groups at both the 12-month (SCARED-C mean score in the intervention group was 4.5 [95% CI, 2.2-6.8] points higher; P < .001; Cohen d = 0.35; and SCARED-P mean score was 3.4 [95% CI, 1.8-5.1] points higher; P < .001; Cohen d = 0.36) and 24-month (SCARED-C mean score in the intervention group was 4.4 [95% CI, 1.7-7.1] points higher; P = .001; Cohen d = 0.29; and SCARED-P mean score was 2.3 [95% CI, 0.1-4.5] points higher; P = .04; Cohen d = 0.19) follow-ups. Overall, the effect size of iCBT increased from 6 months to 12 months, and these results were maintained through 24 months. Statistically significant differences favoring iCBT were also seen in anxiety symptom subgroups. For example, at 12 months, the mean change in social anxiety was 1.6 points higher in the intervention group (95% CI, 1.0-2.3; Cohen d = 0.45). No statistically significant differences were seen in parental mental health. In this cohort study of guided iCBT, the outcomes of the intervention extended through 24 months. This suggests a delayed increase in the effectiveness of the iCBT targeting childhood anxiety, which has important implications for future research and clinical practice.
Clinical relevance
In children aged 10–13 years with elevated anxiety identified through population-level school screening, does a 10-module internet-based cognitive behavioral therapy program with telephone coaching reduce anxiety symptoms more than digital psychoeducation alone at 12 and 24 months? __SNAPSHOT__ {"studyDesign":"Prospective cohort study based on 2-year follow-up data from a previously conducted randomized clinical trial (Master Your Worries; ClinicalTrials.gov NCT03310489). Designated as a cohort study in the JAMA Network Open publication due to the extended observational follow-up design beyond the original RCT.","setting":"Finland; population-based, conducted in school health care settings with recruitment via systematic anxiety screening across multiple municipalities. Conducted August 2017 – January 2020; statistical analyses performed June 2025 – June 2026.","sampleSize":"n=465 (intervention: n=234, control: n=231)","population":"Finnish school children aged 10–13 years (mean age 11.5 years, SD 1.0; 71% female) identified through a two-stage, population-level screening process (>11,000 children initially screened with a 5-item SCARED version; those positive completed the full 41-item instrument) as exhibiting elevated levels of anxiety. A substantial proportion met diagnostic criteria for an anxiety disorder on structured interview.","intervention":"Internet-based cognitive behavioral therapy (iCBT) — 'Master Your Worries' — comprising 10 modules delivered over 10 weeks with weekly digital material, exercises, and weekly telephone coaching calls. Parental participation in telephone calls was also included.","comparator":"Digital psychoeducation about anxiety (internet-based educational control), provided without therapist telephone contact.","primaryOutcome":"Change in participants' anxiety measured by the total score of the Screen for Child Anxiety Related Disorders – Child and Parent versions (SCARED-C/P) at 12 and 24 months.","followUp":"24 months (with assessment points at 6 months [original RCT endpoint], 12 months, and 24 months [this cohort follow-up]).","fundingSource":"Government/non-profit: Research Council of Finland (grant no. 345546) and the APEX consortium (Awareness, Prevention and Early Interventions, grant no. 303581). The lead author (Sourander) is CEO of Digifamilies Inc., a company providing clinical consultation and digital interventions; no direct industry funding of the trial was identified."}
Key findings
Both groups demonstrated reductions in anxiety symptoms over 24 months as measured by SCARED-C and SCARED-P. By 24 months, children in the iCBT group showed greater reductions in both child-reported SCARED-C and parent-reported SCARED-P scores compared with the psychoeducation control group (4.4 points and 2.3 points greater reduction, respectively; p-values, confidence intervals, and Cohen's d for the 12- and 24-month time points are not reported in the available abstract). These between-group differences were not apparent at the 6-month follow-up (the original RCT primary endpoint), at which point the child-reported SCARED total score showed a small but statistically significant advantage for iCBT (p=0.04, Cohen's d=0.17) and parent-reported scores did not differ significantly (p=0.41, d=0.03). Secondary outcome improvements at earlier follow-up included statistically significant iCBT advantages on child-reported generalized anxiety (p=0.047, d=0.09), separation anxiety (p=0.004, d=0.40), and social anxiety (p=0.007, d=0.27), with overall effect sizes characterized by the investigators as small. Scores across domains including panic disorder, social anxiety, and school phobia also decreased more in the iCBT group at 24 months. The investigators noted that benefits appeared to emerge and strengthen over time beyond the 6-month mark, suggesting a delayed therapeutic response. The clinical significance of a 4.4-point SCARED-C difference and a 2.3-point SCARED-P difference at 24 months relative to SCARED scale range and established minimal clinically important difference (MCID) thresholds is not explicitly addressed in the abstract. No severe adverse events were reported in the original RCT phase; adverse event data specific to the 12- and 24-month cohort period are not reported in the available abstract.
Practice implications
This study provides longitudinal evidence that an iCBT program with telephone coaching is associated with greater long-term reductions in child-reported and parent-reported anxiety compared with digital psychoeducation, with the differential benefit becoming more apparent at 12 and 24 months than at 6 months. The study establishes an association, not causation, for the long-term outcomes, as the extended follow-up was conducted as a cohort study rather than a maintained randomized design — the integrity of group allocation and protocol adherence over years 1–2 is uncertain and not described in the abstract. An important observation is that both groups improved substantially, highlighting that population-level screening, assessment, and psychoeducation alone confer meaningful benefit; the incremental advantage of iCBT is real but of small-to-moderate magnitude. The effect appeared greatest in children who met formal diagnostic criteria for an anxiety disorder, suggesting the intervention is most impactful for clinically significant (rather than subclinical) presentations. The finding of a delayed benefit challenges the conventional 6-month endpoint paradigm for pediatric iCBT trials. Findings apply most directly to children aged 10–13 with elevated anxiety identified via structured population screening in a well-resourced European school system. Generalizability to older adolescents, children under 10, non-European health systems, clinical (rather than community-screened) populations, children with severe comorbidities, or settings without structured school-based screening infrastructure is not established. The psychoeducation control was more intensive than 'treatment as usual' in most health systems, potentially underestimating the true effect size of iCBT relative to routine care. The absence of a no-intervention control group means that spontaneous remission cannot be fully distinguished from treatment response. Only the abstract was available for this review; full assessment of statistical methods, handling of missing data, attrition rates at 12 and 24 months, and magnitude of clinical significance requires access to the full manuscript. __LIMITATIONS__ 1. Cohort design for 12- and 24-month follow-up: The long-term phase was not a maintained RCT; potential for differential dropout, contamination between groups, or receipt of additional treatments between 6 and 24 months may confound between-group comparisons.,2. Active and enriched control condition: The digital psychoeducation comparator exceeded standard care in most health systems, likely attenuating the estimated treatment effect of iCBT.,3. Absence of a no-treatment or waitlist arm: Limits ability to distinguish specific iCBT effects from non-specific effects of structured engagement, screening, and assessment.,4. Attrition over 24 months: Retention rates at 12 and 24 months are not reported in the abstract; differential dropout between groups could introduce selection bias.,5. Small effect sizes: Between-group effect sizes at 6 months were small (d=0.17 for SCARED-C, d=0.03 for SCARED-P); whether 24-month differences of 4.4 and 2.3 SCARED points reach established MCID thresholds is not addressed.,6. Sample demographics: 71% female; generalizability to male children and to gender-diverse youth is uncertain and not discussed.,7. Single-country, single-health-system context: Finnish school-based healthcare infrastructure and population-level screening capacity may not be replicable in other settings.,8. Open-label design: Neither participants nor coaches were blinded, introducing risk of performance and detection bias in self-reported outcomes.,9. Surrogate/patient-reported endpoints only: No clinician-rated diagnostic outcomes, functional impairment scales with established MCID, or health service utilization data are described for the 24-month period.,10. Potential conflict of interest: The lead investigator is CEO of a company providing digital interventions; though government-funded, this warrants consideration in interpreting results.,11. Abstract-only review: Full methodological details — including statistical model, handling of missing data, multiple comparison corrections for secondary outcomes, and subgroup analyses — could not be evaluated. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Among Finnish school children aged 10–13 with elevated anxiety identified through population screening, iCBT with telephone coaching was associated with greater reductions in anxiety at 24 months compared with digital psychoeducation, with the differential benefit more pronounced at 2 years than at 6 months. Both groups improved substantially, underscoring the value of screening and psychoeducation alone; the incremental benefit of iCBT appeared most clinically meaningful for children meeting formal anxiety disorder criteria. These findings are promising and support further evaluation of population-based digital iCBT programs, but the cohort design of the long-term follow-up, small effect sizes, enriched control condition, and single-country context indicate that independent replication and full-manuscript review are warranted before broad implementation is recommended.