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Washington State Institute for Public Policy
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Remote cognitive behavioral therapy (CBT) for children with anxiety

Children's Mental Health: Anxiety
Benefit-cost methods last updated December 2019.  Literature review updated May 2018.
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Cognitive behavioral therapy (CBT) uses cognitive restructuring and self-talk, exposure to feared stimuli, and other strategies to treat mental health conditions, including anxiety. Remote CBT interventions are delivered to participants in their homes, via the Internet or workbooks, with limited therapist support by phone or email. In programs in this analysis, 10 to 12 weekly sessions were delivered individually to the child, the parent, or both child and parent. Families were expected to spend an average of 14 hours on the intervention, including time in contact with the therapist. On average, families received four hours of therapist time over three months.
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2018). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $3,896 Benefits minus costs $12,963
Participants $5,865 Benefit to cost ratio n/a
Others $1,578 Chance the program will produce
Indirect $1,069 benefits greater than the costs 95 %
Total benefits $12,408
Net program cost $555
Benefits minus cost $12,963

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
11 8 217 -0.615 0.217 11 -0.243 0.199 12 -1.080 0.001
11 2 66 0.456 0.246 11 n/a n/a n/a 0.825 0.053
11 5 110 -0.506 0.158 11 -0.506 0.158 13 -0.854 0.001
11 3 82 -0.225 0.184 11 0.000 0.310 13 -0.377 0.041
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Major depressive disorder Mortality associated with depression $0 $0 $0 $0 $0
Anxiety disorder Labor market earnings associated with anxiety disorder $2,313 $5,432 $0 $0 $7,745
Internalizing symptoms K-12 grade repetition $55 $0 $0 $27 $82
Health care associated with internalizing symptoms $1,529 $432 $1,578 $765 $4,304
Program cost Adjustment for deadweight cost of program $0 $0 $0 $277 $277
Totals $3,896 $5,865 $1,578 $1,069 $12,408
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $477 2015 Present value of net program costs (in 2018 dollars) $555
Comparison costs $927 2010 Cost range (+ or -) 30 %
In studies included in this analysis, participants received an average of four hours of therapist time. Per-participant cost estimates are based on weighted average therapist time, as reported in the treatment studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer. (2016). Mental health and substance use disorder services data book for the state of Washington). For comparison group costs, we use 2010 Washington State DSHS data to estimate the average reimbursement rate for anxiety treatment for children and adolescents.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Cobham, V.E. (2012). Do anxiety-disordered children need to come into the clinic for efficacious treatment? Journal of Consulting and Clinical Psychology, 80(3), 465.

Conaughton, R.J., Donovan, C.L., & March, S. (2017). Efficacy of an internet-based CBT program for children with comorbid High Functioning Autism Spectrum Disorder and anxiety: A randomised controlled trial. Journal of Affective Disorders, 218, 260-268.

Lenhard, F., Andersson, E., Mataix-Cols, D., Rück, C., Vigerland, S., Högström, J., Hillborg, M., Brander, G., Ljungstrom, M., Ljotsson, B.,& Serlachius, E. (2017). Therapist-guided, internet-delivered cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56(1), 10-19.

Lyneham, H.J., & Rapee, R.M. (2006). Evaluation of therapist-supported parent-implemented CBT for anxiety disorders in rural children. Behaviour Research and Therapy, 44(9), 1287-1300.

Spence, S.H., Holmes, J.M., March, S., & Lipp, O.V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive- behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74(3), 614-621.

Vigerland, S., Ljótsson, B., Thulin, U., Öst, L.G., Andersson, G., & Serlachius, E. (2016). Internet-delivered cognitive behavioural therapy for children with anxiety disorders: A randomised controlled trial. Behaviour Research and Therapy, 76, 47-56.

Wuthrich, V.M., Rapee, R.M., Cunningham, M.J., Lyneham, H.J., Hudson, J.L., & Schniering, C.A. (2012). A randomized controlled trial of the Cool Teens CD-ROM computerized program for adolescent anxiety. Journal of the American Academy of Child & Adolescent Psychiatry, 51(3), 261-270.