Parts of this chapter have been reproduced from Wright et al.1 © 2022 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. The text below includes minor additions and formatting changes to the original text.
Parts of this chapter have been reproduced from Wang et al.2 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. The text below includes minor additions and formatting changes to the original text.
Background and rationale
A specific phobia is an intense, enduring fear of an identifiable object or situation (e.g. dogs, heights or injections) that leads to anxiety, distress and avoidance,3 and is one of the most common mental health difficulties.4 It is estimated that between 5% and 10% of children and young people (CYP) have a specific phobia that is severe enough to affect their everyday functioning,5 and that the average duration of their phobia is 20 years.6 Specific phobias are, therefore, common in the population, are persistent over time and can have significant impacts on health and well-being. For example, specific phobias are associated with poorer health-related quality of life (HRQoL),7 considerable academic difficulties8 and distress and interference with day-to-day activities,9 and may predict a range of future mental health difficulties.10,11 Consequently, it is important that CYP have access to effective treatments for specific phobias so that both the immediate and the possible future impacts can be mitigated. However, the proportion of CYP with phobias who receive treatment for phobia is small, at around 10%,6 and those who do seek treatment are likely to meet barriers and challenges to accessing timely, evidence-based support.12–15
Current treatment approaches for specific phobia
Interventions based on the principles of cognitive–behavioural therapy (CBT) remain the dominant model of delivery of therapy for specific phobias in the Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) programme.16,17 Indeed, CBT for specific phobias and for wider anxiety difficulties is effective and has a robust evidence base.18–20 For example, Hudson et al.21 reported that CBT in children with specific phobias resulted in significant reductions in clinician-rated phobia severity, as well as in both parent-reported and child-reported severity, and a significant increase in specific phobia diagnosis remission at follow-up. However, there are limitations to the provision of CBT. For example, face-to-face CBT is time-consuming22,23 and requires specially trained therapists,24,25 and, therefore, is often offered at high cost and with limited availability.26,27 Furthermore, CBT is often offered over multiple sessions that can take many weeks and months to complete. Given that this requires CYP to be out of school, or the family to travel to receive therapy over many weeks and months, therapy provision can become a burden,28 which might contribute to the relatively high drop-out rate in CBT for CYP.29,30 There is a need for brief, evidenced-based alternative treatments that can be offered in a more time- and cost-efficient manner for CYP living with specific phobias, as well as their families, and the clinical services providing care. One such option, with the potential to offer a brief and clinically effective treatment, is one-session treatment (OST).
One-session treatment: a brief and effective treatment for specific phobia
One-session treatment typically involves a combination of treatment techniques, including exposure, participant modelling, reinforcement, cognitive restructuring and skills training. At the core of OST is gradual exposure to the phobic stimulus, a process directed by the therapist using behavioural experiments.31 Indeed, OST shares many of the same principles as CBT; however, unlike CBT, OST does not require an extensive treatment period. Instead, OST takes place over two sessions: (1) an initial assessment and planning session lasting around 1 hour and (2) one treatment session involving multiple graduated exposures lasting up to 3 hours, a procedure that has been shown to be clinically efficacious in CYP.32–35 For example, in one of the largest randomised controlled trials (RCTs) of OST to date, conducted in the USA and Sweden, Ollendick et al.33 randomised 196 CYP (aged 7–16 years) to one of three groups: (1) an OST group, (2) an education support group and (3) a waiting list control group. The authors reported that OST demonstrated superiority over both the education support group and the waiting list control group in terms of clinician-rated phobia severity, percentage of participants who were diagnosis free, and child ratings of anxiety and treatment satisfaction as reported by the children and their parents post intervention and at a 6-month follow-up point. OST, therefore, could offer a tool that can be used to reduce demands on therapist time, reduce the associated costs, prevent therapeutic drift and ultimately help CYP to recover more quickly from phobia.
Opportunities for advancement
Cognitive–behavioural therapy is the gold standard treatment for specific phobia and represents the dominant model of treatment provision; however, CBT is time-consuming and costly and has limited availability. Although the evidence base to date suggests that OST is a clinically efficacious treatment for phobia, there remain several areas of uncertainty that the present research aims to address. First, extant literature has tended to focus on the efficacy of OST, that is examining the performance of OST under more ‘ideal’ circumstances or in settings that do not reflect the ‘real world’.36 For example, previous trials have tended to exclude participants based on specific characteristics that might influence treatment outcome if OST were to be implemented in clinical services, such as the presence of comorbid mental health difficulties,33 concurrent treatment for other difficulties33 or a diagnosis of autism spectrum disorder (ASD).37 Consequently, it is unclear how well OST would perform in a more ‘real-world’ setting, such as Child and Adolescent Mental Health Services (CAMHS), where therapists are not always able to exclude CYP from therapy based on characteristics that might make treatment delivery more difficult (e.g. psychiatric comorbidity).38,39 Second, to our knowledge, OST has not been compared with routinely delivered CBT with exposure (i.e. the gold standard treatment) in a RCT. Consequently, how OST performs against a much more active treatment, such as CBT, is unclear. Finally, although the consolidated, brief format of OST lends itself to being a more cost-effective tool than multisession CBT, to our knowledge, no study has performed an economic analysis to quantify any (potential) savings. Consequently, the cost-effectiveness of OST relative to CBT is unclear.
Research question, aims and objectives
The present research aims to address the gaps described above by conducting a pragmatic RCT of OST compared with multisession CBT for specific phobias experienced by CYP aged 7–16 years. Specifically, the primary aim of ASPECT (Alleviating Specific Phobias Experienced by Children Trial) is to investigate the non-inferiority of OST compared with multisession CBT for treating specific phobias experienced by CYP at a 6-month follow-up point. Non-inferiority would be demonstrated if OST was shown to produce similar, or improved, effects on the target specific phobia, as assessed using an in vivo exposure assessment tool: the Behavioural Avoidance Task (BAT) (i.e. the primary outcome).40 In addition to the primary aims of ASPECT, several secondary aims are proposed. First, we aim to examine the cost-effectiveness of OST relative to CBT, with the resulting hypothesis being that OST will demonstrate superior cost-effectiveness relative to CBT. Second, the present research aims to investigate not only the effect of OST compared with CBT on the specific phobia itself, but also the impact on a wide range of associated outcomes, including broader mental health, quality of life (QoL), and school and social life. Finally, the present research aims to qualitatively investigate the acceptability of OST to the CYP receiving it, to their parents/guardians and to the clinicians administering OST. In conclusion, we believe that the present research has the potential to provide strong, high-quality evidence from which to base recommendations on not only the clinical effectiveness and cost-effectiveness of OST in real-world clinical settings, but also the perceived acceptability and feasibility of OST to CYP, their guardians and the clinicians responsible for providing care.