Alleviating Specific Phobias Experienced by Children Trial (ASPECT) (ASPECT)
A specific phobia is an intense, enduring fear of an identifiable object or situation that leads to anxiety symptoms, distress, and avoidance (American Psychiatric Association, 2000). It is estimated that between 5% and 10% of children have a specific phobia severe enough to impact on their everyday functioning (Kessler et al., 2007) and that the average duration of their phobias is 20 years (Stinson et al., 2007). The mental health, developmental and medical impact of these phobias is significant, with higher rates of health service usage than most other anxiety disorders (Deacon, Lickel, & Abraowitz, 2008), despite the fact that fewer than 10% seek treatment for the phobia itself (Stinson et al.,2007). This can result in considerable academic difficulties lalongo, Edelsohn, Werthamerlarsson, Crockett & Kellman, 1995), personal distress (Ollendick & March, 2004) and interference in day-to-day activities (Ollendick, King, & Muris, 2004).
Current Treatment Approaches
Cognitive behavioural therapy (CBT) remains the dominant model of therapy delivery in Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) for specific phobias (Kendall & Hedtke, 2006; Kendall et al., 2005). Indeed, evidence supporting the efficacy of CBT for anxiety disorders and phobias is robust (Butler, Chapman, Forman, & Beck, 2006; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Hofmann & Smiths, 2008), consequently CBT is often the first choice psychological treatment for these problems. However, there are limitations to the provision of CBT. For example, face-to-face CBT is time consuming (Aschim, Lundevall, Martisen, & Frich, 2011; Wiebe & Greiver, 2005), is often offered at great cost and, thus, has limited availability (Cavanagh, 2-14; Shapiro, Cavanagh, & Lomas, 2003. As a result, clinical services are moving towards improving patient outcomes by working with low intensity treatments that have the potential to be implemented across the NHS (Bower & Gilbody, 2005; National Collaborating Centre for Mental Health, 2011). One such low intensity alternative to CBT that shows potential is One-Session Treatment (Öst, 1989).
One-Session Treatment: An Overview
Unlike CBT, OST does not require an extensive treatment period. Instead, a combination of treatment techniques including graduated exposure therapy, participant modelling, reinforcement, psycho-education, cognitive challenges and skills training are consolidated into a single three-hour session, a procedure which has been shown to be clinically effective in children (Ollendick et al., 2009; (Öst,Svensson, Hellstrom, & Lindwall, 2001; Ryan, Strege, Oar, & Ollendick, 2017). For example, in one of the largest trials of OST, Ollendick et al. (2009) randomised 196 children (ages 7 to 16) to one of three groups; i) an OST group; ii) an education support group; and iii) a wait-list control group. The authors reported that OST demonstrated superiority over both the education support group and the wait-list control in terms of clinician rated phobia severity, percentage of participants who were diagnosis free, child ratings of anxiety and treatment satisfaction as reported by the children and their parents at post-intervention and a six-month follow-up point. OST, therefore, appears well placed to provide a low intensity alternative to CBT for specific phobias.
CBT is the dominant model of treatment provision in the UK, and more generally. However, as discussed in the previous section, the provision of CBT is time consuming, offered at great cost and is limited in terms of its availability. Indeed, existing therapist resources struggle at best to treat the existing large numbers of young people in need of help with their anxiety and phobia problems. Consequently, there is great need for evidence based, alternative, low intensity psychological therapies that are able to bridge the gap between those needing treatment and the sparse availability of resources. The present research aims to provide high quality evidence of the non-inferiority of OST when compared to standard CBT in two ways; i) in terms of treatment efficacy; and ii) in terms of economic viability. Furthermore, ASPECT intends to investigate engagement from participants and clinicians alike whilst ensuring the proposed research runs within a pragmatic, ‘real-world’ setting. A more detailed overview of the aims of ASPECT is outlined below.
The Non-Inferiority of OST compared to CBT
Although OST has demonstrated efficacy in comparison to an active control group, it is yet to be compared against the primary treatment choice in the UK, CBT. Should OST demonstrate non-inferiority when compared with CBT (i.e. similar or better efficacy) alongside economic advantages, the evidence in favour of OST for specific phobias would be considerably strengthened.