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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 2017.  Literature review updated April 2012.
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These treatments utilize the same principles and techniques as those of other Cognitive Behavior Therapy (CBT) treatments for anxiety (e.g., strategies to control physiological responses to anxiety, cognitive restructuring and self-talk, exposure to feared stimuli, and positive reinforcement). However, they are unique insofar as clients have reduced (if any) face-to-face time with therapists. Clients are supported remotely via email or phone contact. A manual or online program helps to guide progress of the intervention.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). 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 $2,017 Benefits minus costs $7,599
Participants $3,977 Benefit to cost ratio n/a
Others $296 Chance the program will produce
Indirect $518 benefits greater than the costs 93 %
Total benefits $6,808
Net program cost $791
Benefits minus cost $7,599
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
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
K-12 grade repetition $8 $0 $0 $4 $11
Labor market earnings associated with major depression $1 $1 $0 $0 $2
Health care associated with major depression $0 $0 $0 $0 $0
Labor market earnings associated with anxiety disorder $1,779 $3,918 $0 $0 $5,698
Health care associated with anxiety disorder $244 $80 $302 $123 $749
Costs of higher education ($15) ($22) ($7) ($7) ($50)
Adjustment for deadweight cost of program $0 $0 $0 $399 $399
Totals $2,017 $3,977 $296 $518 $6,808
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $217 2010 Present value of net program costs (in 2016 dollars) $791
Comparison costs $943 2010 Cost range (+ or -) 10 %
Per-participant costs are based on average therapist time, as reported in the treatment studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer. (2013). Behavioral Health Data Book for the State of Washington for Rates Effective January 1, 2014). Comparison costs are based on the average reimbursement for treatment of child anxiety.
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.
Estimated Cumulative Net Benefits Over Time (Non-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 non-discounted dollars to simplify the “break-even” point from a budgeting perspective. 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.

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

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

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.

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
Anxiety disorder 10 5 210 -0.439 0.285 11 -0.203 0.142 12 -1.141 0.001
Global functioning^ 10 2 46 0.451 0.212 11 0.209 0.110 12 1.074 0.001
Major depressive disorder^^ 10 1 30 0.000 0.260 11 0.000 0.021 12 0.000 1.000

Citations Used in the Meta-Analysis

Khanna, M.S., & Kendall, P.C. (2010). Computer-assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 78(5), 737-745.

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.

March, S., Spence, S.H., & Donovan, C.L. (2009). The efficacy of an internet-based cognitive-behavioral therapy intervention for child anxiety disorders. Journal of Pediatric Psychology, 34(5), 474-487.

Rapee, R.M., Abbott, M.J., & Lyneham, H.J. (2006). Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444.

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.