BRAVE-ONLINE elicits a strong reduction in anxiety for most young people, irrespective of age, sex, type and severity of anxiety and parent mental health

Last updated 12 January 2024

In the wake of the current coronavirus pandemic, more practitioners are turning to online service delivery for children and adolescents in need of mental health support. The recent JCPP publication from Susan Spence and colleagues on internet-delivered cognitive behaviour therapy (iCBT) for anxious children is thus particularly timely.

Spence et al. invited 175 children (aged 7-18 years) with an anxiety disorder and one of their parents to complete an iCBT intervention known as BRAVE-ONLINE.1 The children received brief, online therapist support. The researchers collected child- and parent-reported anxiety scores at baseline and at various time points up to 1 year after completing. They found that most young people responded well to iCBT: most completed the program, and showed a strong and significant reduction in anxiety symptoms.

Interestingly, variation in the level of change in anxiety symptoms warranted an examination of predictors of outcome. They thus examined whether they could predict an improvement in anxiety symptoms during and after treatment from a range of child and family characteristics. While the improvements seen in anxiety symptoms occurred irrespective of most of the demographic, clinical and family factors examined, they could predict a slightly poorer response to iCBT if the child lived in a family where the parents experienced a poor relationship quality, or the mother was older rather than younger.

“There are now several controlled research trials showing that iCBT with minimal therapist support, can produce significant improvements in anxiety for children and adolescents presenting with anxiety disorders”, says Spence. “However, we cannot assume that iCBT is suitable for all clinically anxious children and it is important that we identify the characteristics of children who respond well versus those who do not”. Indeed, there are likely to be other factors not investigated in this study that might affect the response to iCBT. For example, the amount of help provided by parents to the child in completing the program, or the presence of conduct or attention deficit disorders, was not assessed at this time. Spence et al. propose that future research might examine whether these factors are potential predictors of the iCBT response for child anxiety.

“Certainly for now, delivering cognitive behaviour therapy using the internet rather than face-to-face offers a way of increasing access to treatment for many young people with mental health problems who would otherwise not receive the help they need”, says Spence. “With the COVID-19 virus not only impacting upon the mental wellbeing of young people, but also restricting the opportunities for receiving clinic-based treatment, the option of effective iCBT for youth mental health is more important than ever.”

Video abstract

Referring to

Spence, S.H., Prosser, S.J., March, S. & Donovan, C.L. (2020), Internet‐delivered cognitive behavior therapy with minimal therapist support for anxious children and adolescents: predictors of response. J. Child Psychol. Psychiatr. doi: 10.1111/jcpp.13257.


1Spence, S.H. et al. (2008). Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE-ONLINE and two case illustrations. Behav. Cogn. Psychother. 36:411– 430. doi: 10.1017/S135246580800444X.

Dr Jessica Edwards
Jessica received her MA in Biological Sciences and her DPhil in Neurobehavioural Genetics from the University of Oxford (Magdalen College). After completing her post-doctoral research, she moved into scientific editing and publishing, first working for Spandidos Publications (London, UK) and then moving to Nature Publishing Group. Jessica is now a freelance editor and science writer, and started writing for “The Bridge” in December 2017.

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