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Journal of Anxiety Disorders 31 (2015) 1–10

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

redictors of dropout from community clinic child CBT for anxietyisorders

ro Janne H. Wergeland a,b,∗, Krister W. Fjermestad a,c, Carla E. Marin d,ente Storm-Mowatt Haugland a,e, Wendy K. Silverman d, Lars-Göran Öst a,f,g,h,dd E. Havik a,f, Einar R. Heiervang a,i,j

Anxiety Research Network, Haukeland University Hospital, Bergen, NorwayDepartment of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, NorwayFrambu Resource Centre for Rare Disorders, Siggerud, NorwayChild Study Center, Yale University School of Medicine, New Haven, CT, USARegional Centre for Child and Youth Mental Health and Child Welfare, Uni Research Health, Bergen, NorwayDepartment of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, NorwayDepartment of Clinical Neuroscience, Karolinska Institutet, Stockholm, SwedenDepartment of Psychology, University of Stockholm, Stockholm, SwedenInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, NorwayDivision of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway

r t i c l e i n f o

rticle history:eceived 17 March 2014eceived in revised form8 November 2014ccepted 8 January 2015vailable online 22 January 2015

a b s t r a c t

The aim was to investigate predictors of treatment dropout among 182 children (aged 8–15 years) par-ticipating in an effectiveness trial of manual-based 10-session individual and group cognitive behaviortherapy (CBT) for anxiety disorders in community clinics. The dropout rate was 14.4%, with no significantdifference between the two treatment conditions. We examined predictors for overall dropout (n = 26),early (≤session 4, n = 15), and late dropout (≥session 5, n = 11). Overall dropout was predicted by lowchild and parent rated treatment credibility, and high parent self-rated internalizing symptoms. Low

eywords:ropoutffectivenessognitive behavior therapynxiety

child rated treatment credibility predicted both early and late dropout. High parent self-rated internal-izing symptoms predicted early dropout, whereas low parent rated treatment credibility predicted latedropout. These results highlight the importance of addressing treatment credibility, and to offer supportfor parents with internalizing symptoms, to help children and families remain in treatment.

© 2015 Elsevier Ltd. All rights reserved.

hildren

Treatment dropout is a challenge in child and adolescent men-al health care with a dropout rate up to 50% reported for childrenreated in community mental health clinics (de Haan, Boon, de Jong,oeve, & Vermeiren, 2013; Wierzbicki & Pekarik, 1993). Dropout

rom therapy has been shown to negatively impact both clientsnd therapists (Pekarik, 1992; Swift & Greenberg, 2012), and isssociated with inefficient use of services (Armbruster & Kazdin,994; Pekarik, 1985). Also, treatment dropout impedes the deliv-ry of otherwise efficacious treatments, such as cognitive behaviorherapy (CBT), which is an evidence-based treatment for anxiety

isorders in children (James, James, Cowdrey, Soler, & Choke, 2013;ilverman, Pina, & Viswesvaran, 2008).

∗ Corresponding author at: Department of Child and Adolescent Psychiatry,aukeland University Hospital, N-5021 Bergen, Norway. Tel.: + 47 48176828.

E-mail address: gjwergeland@gmail.com (G.J.H. Wergeland).

ttp://dx.doi.org/10.1016/j.janxdis.2015.01.004887-6185/© 2015 Elsevier Ltd. All rights reserved.

Identifying predictors of treatment dropout for children withanxiety disorders are important, since these disorders are bothhighly prevalent (Costello, Mustillo, Erkanli, Keeler, & Angold,2003), and are associated with increased risk of later anxiety,depression and substance abuse disorders (Rapee, Schniering, &Hudson, 2009). Anxious children are often shy and withdrawn,making them challenging to engage in the therapy. Furthermore,CBT entails exposure tasks, which may cause discomfort and maytrigger avoidance behavior (Kendall et al., 2009). Identifying predic-tors for treatment dropout could therefore help identify children atrisk for dropout for whom interventions to promote continuationcould be implemented (Kendall & Sugarman, 1997; Nock & Kazdin,2005; Pina, Silverman, Weems, Kurtines, & Goldman, 2003).

To date, only three studies have examined predictors of treat-

ment dropout in child anxiety therapies (Gonzalez, Weersing,Warnick, Scahill, & Woolston, 2011; Kendall & Sugarman, 1997;Pina et al., 2003). Two of the studies were randomized controlledefficacy CBT trials conducted at specialized university child anxiety

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linics. In the first of these studies, dropouts more often had beenandomized to the wait-list condition, came from single parentamilies, and reported less self-rated anxiety symptoms at baselineKendall & Sugarman, 1997). In the other study, no significant dif-erences between treatment completers and dropouts were foundPina et al., 2003). In these two studies, the dropout rate was similar,t 23.2% and 22.6%, respectively. In contrast to these two stud-es, Gonzalez et al. (2011) examined predictors of overall dropout,nd predictors of early (session 2–6) and late (≥7 session) dropoutrom uncontrolled eclectic youth anxiety treatment in a commu-ity clinic. The authors reported that overall dropout was predictedy higher caregiver-rated youth depressive symptoms at pretreat-ent. When distinguishing between early and late dropout from

reatment, early dropout was predicted by ethnic minority sta-us, whereas late dropout was predicted by higher caregiver-ratedouth depressive symptoms. In this study, the dropout rate wasigh, at 51.3%.

In sum, there are few studies investigating predictors of dropoutn child anxiety treatment, and findings are scarce. Importantly,ast studies have focused mainly on identifying demographic fac-ors or child and parent clinical factors (e.g., child symptoms ofnxiety, depression, and externalizing behavior, and parent symp-oms of anxiety and depression) associated with dropout. Althoughhese factors are related to treatment dropout in child mentalealth services (de Haan et al., 2013), they provide little informa-ion on reasons for children’s failure to complete treatment (Nock

Ferriter, 2005). Moreover, demographic factors are unlikely tohange during treatment. Identifying factors that are amenable tohange at treatment onset could serve a preventive function, ashese could be addressed before and during the early phase ofherapy to promote continuation (de Haan et al., 2013; Greenberg,onstantino, & Bruce, 2006; Kazdin, 1996).

Possible factors amenable to change early in treatment includehe underlying processes of treatment variables such as treatmentelief factors. Kazdin, Holland, and Crowley (1997) developed theBarriers to treatment” model, referring to stressors and obstaclesssociated with treatment participation, including perceptions thatreatment is demanding and not relevant to the child’s problem.ncluding treatment belief factors in predictor studies of dropoutould improve our understanding of dropout in children with anx-ety disorders.

Two such treatment belief factors are the (1) the child’s motiva-ion (i.e., child acknowledgement of problems, perceived distress,nd willingness to change; Keijsers, Schaap, Hoogduin, Hoogsteyns,

de Kemp, 1999), and (2) perceived treatment credibility (i.e., howogical, plausible and believable the treatment is perceived to be;azdin, 1979). As most children do not seek treatment themselves,otivation for entering and remaining in treatment may be lower

han in adult patients. For developmental reasons, children mayave limited or inaccurate perceptions of what treatment entails.

n adults, low motivation for treatment, poor treatment credibil-ty, low readiness for change, preference for a particular treatment,nd poor therapeutic alliance, have been associated with dropoutn CBT for anxiety disorders (Taylor, Abramowitz, & McKay 2012).

otivation and treatment credibility may be particular relevant inreatment of anxious children, in order to face demanding exposureasks in CBT (Kendall et al., 2009). To date, these factors have noteen examined in relation to dropout in studies of children withnxiety disorders.

Alongside treatment beliefs, children’s self-beliefs may alsonfluence their risk of dropping out from treatment. Anxious chil-ren tend to report negative self-instructions in anxiety-provoking

ituations, which may challenge their treatment endurance (Silkt al., 2013). Children’s self-concept, defined as their self-ompetence and self-worth (Beck, Beck, & Jones, 2001), has beenound to be related to endurance, positive coping strategies, and

xiety Disorders 31 (2015) 1–10

achievement (Bong & Skaalvik, 2003). Thus, self-concept is a pos-sible predictor of dropout from child anxiety treatment that iswarranted investigation.

Although child self- and treatment beliefs may influencedropout risk, parents are important agents in seeking help andtreatment for the child, and are often the main agents in helpingthe child adhere to treatment (Armbruster & Kazdin, 1994). Fur-thermore, parents regularly participate in the treatment programsfor child anxiety (Breinholst, Esbjorn, Reinholdt-Dunne, & Stallard,2012). Parental depression and anxiety may interfere with theirability to support their child’s treatment. In treatment studies ofchild conduct disorders, parent psychopathology has been found tobe related to dropout, with depressed, and stressed parents beingless able to follow up on clinical appointments (Kazdin, 1996). Theeffect of parents’ anxiety and depressive symptoms on dropoutfrom child anxiety treatment has only been examined in one study(Kendall & Sugarman, 1997). Although this university clinic trialfound no association between parental internalizing symptoms anddropout, these results may not be generalizable to community clin-ics. Higher levels of life stressors have been reported for families incommunity clinics compared to research clinics (Southam-Gerow,Chorpita, Miller, & Gleacher, 2008; Southam-Gerow, Weisz, &Kendall, 2003), that may negatively affect parent’s emotional wellbeing, and thus their ability to follow up on the child’s treatment.Thus, parental internalizing symptoms are important to evaluateas potential predictors of dropout in community clinics.

In addition to the challenge of identifying relevant predictors ofdropout, another methodological problem in this field of research isthe variation in methods used to operationalize treatment dropout.Two child anxiety studies defined dropout as failure to complete atreatment protocol, i.e., dropout prior to completing the full courseon an intervention (Kendall & Sugarman, 1997; Pina et al., 2003);whereas one study defined dropout by therapist judgment, i.e.,after a client discontinued therapy, the therapist decided whetherthe client dropped out prematurely (Gonzalez et al., 2011). Thisvariation in dropout definitions makes results across studies dif-ficult to compare. However, different definitions of dropout maybe relevant depending on the question under study. For instance,efforts to implement evidence-based treatments for children withanxiety disorders are currently carried out in community clinics.CBT programs for children with anxiety disorders commonly havea predefined number of sessions in the treatment protocol, withexposure tasks often instituted mid-treatment. Thus, when deliv-ering CBT programs in community clinics, it would be relevant toexamine the rate of participants that do not complete a full treat-ment protocol, and associated predictors of dropout.

Another relevant distinction of dropouts is between childrenwho drop out early and late in treatment. Different factors may beassociated with dropout from a specific phase in the treatment pro-cess, and collapsing early and late dropouts into one group couldtherefore mask important differences (Kazdin & Mazurick, 1994).One may expect that early dropout relates more to pretreatmentsymptoms and functions, while late dropout could relate more tothe form and content of the treatment itself. It has been found thatthe majority of dropout occurs early in treatment (Garfield, 1994),and early dropout is associated with poorer outcomes (Pekarik,1992). If specific predictors of early dropout could be identified,these could be targeted early in treatment in an attempt to preventdropout. Similarly, predictors associated with late dropout could beaddressed during treatment to help families remain in treatment.Gonzalez et al. (2011) found that predictors of treatment dropoutwere related to when in the treatment process dropout occurred,

distinguishing between overall, early and late dropout. Further-more, in a study of self-help treatment for adults with anxiety, theintroduction of exposure tasks seemed to challenge treatment com-pliance (Holden, O’Brien, Barlow, Stetson, & Infantino, 1983). Thus,

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dentifying factors that predict early and late dropout could provide further understanding of what is needed both to prevent dropoutnd promote continuation.

In the present study, we examined predictors of treatmentropout from an effectiveness trial of a manualized CBT program

or anxiety disorders in children (Wergeland et al., 2014). Poten-ial predictors included demographic variables, and clinical- andreatment belief variables assessed by child and parent. In thenalyses, three groups of dropout were used: overall dropout,arly dropout, and late dropout. In line with previous findings,e hypothesized that children from single parent families, chil-

ren with low anxiety symptom levels, or with elevated levels ofepressive symptoms would be at higher risk for dropping out. Inddition, we hypothesized that children with low self-concept, lowotivation, and low perceived treatment credibility, and children

f parents with elevated levels of self-rated internalizing symp-oms, and low perceived treatment credibility would be at higherisk for dropping out of treatment. We had no particular hypothe-es concerning the predictors’ respective role for early versus lateropout, but included this to provide further insights into which

actors should be targeted at which stage of treatment to preventropout.

. Method

This trial is part of a randomized waitlist controlled trial (RCT)NCT00586586, clinicaltrials.gov), the methods and main outcomesf which are described elsewhere (Wergeland et al., 2014). Ethicalpproval for the study was obtained from the Regional Commit-ee for Medical and Health Research Ethics. The main aim of theCT was to investigate the effectiveness of CBT, and to comparehe relative effectiveness of individual CBT (ICBT) and group CBTGCBT) treatment for anxiety disorders in children and adolescents.

description of participants, interventions, measures and studyesign is presented here with emphasis on dropout.

tudy setting

The study was conducted in seven public child and adoles-ent mental health outpatient clinics, covering both rural andrban areas. Each clinic covers a given catchment area, and has anmphasis on severe, complex, and disabling conditions. Childrenre referred to the clinics by general practitioners or less often byhild welfare services. Services are free of charge for all families andhere is only marginal use of private mental health care for youthn Norway.

articipants

The sample comprised 182 children (aged 8–15 years, M = 11.5,D = 2.1, 53.5% girls) and one of their parents (92.0% mothers).he inclusion criteria were a primary diagnosis of separation anx-

ety disorder (SAD), social phobia (SOP) or generalized anxietyisorder (GAD) according to the DSM-IV (American Psychiatricssociation, 1994). Exclusion criteria were pervasive developmen-

al disorder, psychotic disorder, and/or mental retardation. Youthn psychotropic medication (6.0%) were not excluded, if dosagead been stable for the last 3 months prior to entering the studynd kept constant during the treatment period.

Most participants were Caucasian (90.7%), while 1.6% weresian, and for 7.7% ethnicity was not reported. The majority livedith both biological parents (57.7%), and 90.7% were living with

t least one biological parent. Parent occupation was classified intoank ordered social classes in accordance with the Registrar Generalocial Class coding scheme (Currie et al., 2008), with family sociallass defined by the highest ranking parent. Family social class was

xiety Disorders 31 (2015) 1–10 3

high for 30.7%, medium for 50.5%, low for 7.7%, and unknown for11.1%.

Treatment

The treatment was FRIENDS for life; 4th ed. (Barrett, 2004),a 10-session manual-based CBT program addressing cognitive,physiological, and behavioral components that interact in thedevelopment and maintenance of anxiety. There are two separateversions of the program that are adjusted for developmental level.The child version was used for children aged 8–12, and the adoles-cent version was used for ages 12–15. Children aged 12 year oldscould be included in either age group, based on clinician evaluationof maturity level.

Procedures

Informed written consent from parents, and assent from chil-dren aged 12 years or older, was obtained prior to the inclusionassessment. Following inclusion, children were randomly assignedto ICBT, GCBT, or a waitlist control condition. Children still meet-ing criteria for inclusion after waitlist were randomized to ICBT orGCBT, giving a total of 181 children randomized to treatment. Themean duration was 10 weeks both for the treatment program andthe waitlist period, with weekly therapy sessions lasting 60 min forICBT and 90 min for GCBT. Parents attended 2 of the 10 child ses-sions, 2 separate parent sessions, as well as the last 15 min of theother eight sessions.

The rationale for and contents of the treatment program wereexplained in the first treatment session by the therapists. Partici-pants who missed sessions were contacted by their therapist andoffered individual replacement sessions. Parents of children whodropped out were contacted by the therapist, and reasons for treat-ment dropout were assigned to each case at discharge.

Definition of dropout

Overall treatment dropout was defined as failure to complete afull treatment protocol, a definition widely used in evidence-basedtreatment programs (Swift & Greenberg, 2012). In accordance withthis, children were defined as treatment completers if they partici-pated in at least seven sessions of the 10-session program, includingthe final treatment session and the post treatment assessment.Children absent from more than three sessions were consideredas dropouts.

Of the 26 dropouts (14.4%), six declined to start treatmentas offered, and 20 did not complete the treatment after havingstarted. Decliners either dropped out while on waitlist (n = 2), orafter randomization (n = 4). There were no significant differencesin demographic or clinical variables between decliners and non-completers (data not shown). Also, dropout rates from GCBT andICBT were not significantly different (10.2% vs. 16.5%, p = .27). Alldropouts were therefore combined into a single group for statisticalanalyses.

To define early and late dropout, session five was chosen as thecutoff, not only for being midpoint of treatment, but because inthe following sessions exposure training is introduced, which isconsidered to be one of the critical factors of anxiety treatment(Holden et al., 1983; Kendall et al., 2009). According to this defini-tion, 15 children were early dropouts (≤4th session), and 11 werelate dropouts (≥ 5th session).

Reasons for treatment dropout were collected by the thera-

pists, and assigned to each case at discharge (Armbruster & Kazdin,1994). Reasons were categorized as follows: Motivational issues(low patient motivation for treatment at time of termination,n = 11), Referred to other treatment (psychotic disorder, n = 1, PTSD,

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= 2), Improved (patient not longer feeling in need of treatment, = 3), Withdrawn consent (n = 1) or Other (preference for differ-nt treatment format, n = 2; severe depressive symptoms needingedication, n = 2; group climate, n = 1; practical barriers, n = 3). The

ollected information from the therapists was reviewed and codedy two of the authors. The raters demonstrated good inter-ratereliability (� = 0.83).

easures

iagnostic interviews for study entry

The Anxiety Disorder Interview Schedule for DSM-IV, child andarent versions (ADIS-C/P; Silverman & Albano, 1996); SAD, SOPnd GAD modules were used to assess inclusion diagnoses. Thehild and parents were interviewed separately, and diagnoses andlinician severity ratings (CSR) were assigned based on the com-ined parent and child report. A CSR of four or above (on the 0–8cale) was required for inclusion. The ADIS-C/P has demonstratedxcellent inter-rater reliability; retest reliability and concurrentalidity (Lyneham, Abbott, & Rapee, 2007; Silverman, Saavedra,

Pina, 2001; Wood, Piacentini, Bergman, McCracken, & Barrios,002). A blind rescoring of 20% of the interviews gave kappa valuesor the presence of an inclusion anxiety diagnosis of 0.84 (ADIS-) and 0.86 (ADIS-P), whereas the CSR intraclass correlation (ICCs)as 0.82 both for ADIS-C and ADIS-P.

The Development and Well-Being Assessment (DAWBA;oodman, Ford, Richards, Gatward, & Meltzer, 2000) was com-leted as part of the routine intake procedure at the participatinglinics. The DAWBA is a web-based diagnostic interview, com-ining structured questions on symptoms and impairment withpen-ended questions for detailed accounts of symptoms and

mpairment. The caregiver, and the child him/herself from age 11ears, completed the interview online. Parent and youth DAWBAnformation was used to assess comorbid disorders other than SAD,OP and GAD, and for providing demographic information. TheAWBA has been found to discriminate well between commu-ity and clinic samples of youth (Goodman et al., 2000), and hashown good to excellent inter-rater reliability (Ford, Goodman, &eltzer, 2003). In the current study, a blind rescoring of 24% of the

nterviews gave kappa values ranging from satisfactory to excellent� = 0.58 for other anxiety, 0.66 for ADHD, 0.72 for Specific Phobia,.77 for Depression, and 1.00 for ODD, PDD and Tic disorders).

hild and parent rated child symptom measures

Spence Children’s Anxiety Scale (SCAS; Spence, 1998), childnd parent versions, were used to assess child anxiety symp-oms. The SCAS comprises 38 items, rated on a 4-point scale0 = never; 3 = always) yielding a maximum score of 114. A 6 monthsest–retest reliability of .60 for the total SCAS score has beeneported (Spence, 1998; Spence, Barrett, & Turner, 2003). Inter-al consistency for the SCAS in the current sample was good toxcellent (Chronbach’s ˛: parent = .85, child = .91).

Short Mood and Feelings Questionnaire (SMFQ; Angold,ostello, Messer, & Pickles, 1995), child and parent versions, weresed to assess child depressive symptoms. The SMFQ comprises3 items rated on a 3-point scale (0 = not true, 2 = true), yielding aaximum total score of 26. Two-weeks test–retest reliability has

een found to be .66 for child ratings and .88 for parent ratingsKuo, Stoep, & Stewart, 2005). The SMFQ has been found to dis-

riminate well between psychiatric and non-psychiatric patientsAngold et al., 1995; Kuo et al., 2005; Sharp, Goodyer, & Croudace,006). In the current sample internal consistency was good (Chron-ach’s ˛: parent = .86, child = .88).

xiety Disorders 31 (2015) 1–10

Child self-concept

Self-Concept Scale (SCS) of the Beck Youth Inventories of Emo-tional and Social Impairment (Beck et al., 2001) was used to assessthe children’s self-concept. The SCS comprises 20 items relatedto competence and self-esteem (e.g., I’m pleased with myself, I’mproud of what I do), rated on a 4-point scale (0 = never, 3 = always),with lower values indicating lower self-concept. High internal con-sistency and good retest reliability has been reported for this scale(Beck et al., 2001). Internal consistency of the SCS in the currentsample was excellent (Chronbach’s ̨ = .93).

Parent self-rated internalizing symptoms

Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond,1995) was completed by parents, and used to assess parental self-rated depression, anxiety and tension-stress. The DASS consists of42 items; each rated on a 4-point scale (0 = hardly ever, 3 = almostalways). The questionnaire has demonstrated satisfactory reliabil-ity, convergent and discriminant validity with other instruments(Brown, Chorpita, Korotitsch, & Barlow, 1997; Lovibond & Lovibond,1995). Internal consistency of the DASS in the current sample wasexcellent (Chronbach’s ̨ = .95).

Motivation and treatment credibility

Nijmegen Motivation List–child version (NML; Keijsers et al.,1999). NML was developed to assess treatment motivation inadults, and was modified for use with children. The NML adaptedfor children consists of 15 items (e.g., I believe that this is the righttreatment for me), scored on a 3-point scale. Internal consistencyof the NML-c in the current sample was good (Chronbach’s ̨ = .86).

Credibility Scale–child and parent versions (CS; Borkovec & Nau1972) was used to assess perceived treatment credibility. The CS-C/P consists of four items (e.g., How confident are you that thistreatment will help your anxiety?) and is scored on a 9-point (0–8)scale. The CS has demonstrated discriminant validity in a child-hood phobia study comparing exposure to non-exposure treatment(Ollendick et al., 2009). Internal consistency of the CS in the currentsample was good (Chronbach’s ˛: parent = .82, child = .84).

All questionnaires were completed at the pretreatment assess-ment, except for the Credibility Scale, which was administered atthe end of the first treatment session, after youth and parents hadbeen informed about the rationale for and contents of the treatmentprogram.

Data analytic plan

A two-step data-analytic strategy was used. First, linear-and logistic regression analyses were conducted to test for dif-ferences in baseline demographics, clinical child- and parentfactors, and treatment process factors between completers anddropouts, and between early and late dropouts. Second, multivari-ate logistic regression and multinomial logistic regression analysiswere conducted to predict overall dropout, and early and latedropout. Analyses were conducted separately for child- and parentrated measures. Significant predictors from either informant wereincluded in a final multivariate or multinomial regression analysis.

We used the six selected child variables (single-parent family,child self-rated depressive and anxiety symptom severity, childself-concept, motivation, child perceived treatment credibility),and the five parent variables (single parent family, parent-rated

child depressive and anxiety symptom severity, parent self-ratedinternalizing symptoms, and parent perceived treatment credibil-ity) as predictors in both the logistic and multinomial regressionanalyses. In addition, age was included in the analyses as age was

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Table 1Pretreatment characteristics of completers and dropout.

Subgroup Time of dropout

Total sample Completers Dropouts Early (≤4 sessions) Late (≥5 sessions)

N (%) 182 155 (85.6%) 26 (14.4 %) 15 (57.7 %) 11 (42.3 %)

% M SD % M SD % M SD % M SD % M SD

GenderMale 47.3 47.7 42.3 40.0 45.5Female 52.7 52.3 57.7 60.0 54.5

Age 11.54 2.09 11.46 2.07 12.04 2.16 11.60 1.76a 12.64 2.58b

Age group8–12 yrs 65.9 67.7 53.8 60.0 45.512–15 yrs 34.1 32.3 46.2 40.0 54.5

Family structure*

Single parent family 19.8 20.0 19.2 20.0 18.2Comorbidity present 77.9 79.4 69.2 66.7 72.7Comorbid disorders not AD* 34.1 35.5 26.1 7.1 55.6Child completed measures

SCAS-c 36.05 16.64 36.49 16.96 34.72 13.60 32.03 13.52 38.48 13.49SMFQ-c 7.48 5.55 7.33 5.26 8.33 7.06 7.09 5.44 9.91 8.72CS-c 22.80 6.60 23.47 6.00a 16.08 8.58b 14.83 11.89 17.14 5.15SCS 34.79 11.32 35.50 11.29a 30.60 10.81b 32.62 10.03 28.22 11.67NML 19.84 5.84 19.97 5.73 19.10 6.51 17.54 7.62 20.94 4.55

Parent completed measuresSCAS-p 34.65 12.74 35.00 12.34 33.46 14.63 34.43 15.74 32.01 13.47SMFQ-p 7.53 5.02 7.58 5.03 7.23 5.08 7.13 6.05 7.38 3.45CS-p 24.16 4.77 24.34 4.76 21.89 4.54 24.00 4.24a 19.25 3.77b

DASS 12.03 14.52 11.18 13.21 16.68 19.96 18.41 24.65 14.10 10.26

Note: a,b Values within the same subtable with different superscript letters are significantly different at p < 0.05.* Based on combined information from youth and parents for participants 11 years or older, otherwise on parents report only. AD = Anxiety disorders; SCAS = Spence Child Anxiety Scale; SMFQ = Short Mood and Feelings

Questionnaire; CS = Credibility Scale; SCS = Self Concept Scale; NML = Nijmejgen Motivational List; DASS = Depression, Anxiety and Stress Scales; c = child; p = parent.

6 G.J.H. Wergeland et al. / Journal of Anxiety Disorders 31 (2015) 1–10

Table 2Correlations among study variables.

Dropout SCAS-c MFQ-c CS-c SCS NML SCAS-p MFQ - p CS-p

Dropout –SCAS-c −.03 –MFQ-c .06 .48*** –CS-c −.38*** .27** .08 –SCS −.15** −.25*** −.50*** .18 –NML −.04 .48*** .34*** .34*** .01 –SCAS-p −.05 .26** .10 .13 .05 .15* –MFQ -p −.03 .07 .34*** −.05 −.20* .13 .38*** –CS-p −.13 −.13 −.08 .34*** .24** .04 .18 .01 –DASS .14 .10 .06 .11 −.05 .15 .27*** .32** −.05

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only treatment credibility significantly predicted dropout aftercontrolling for the other predictor variables. For parent-rated meas-ures, both treatment credibility and parent self-rated internalizingsymptoms significantly predicted dropout. However, the explained

Table 3Logistic regression results for predictors of dropout.

OR 95% CI for OR �R2 p

ChildrenCS-c 0.32 [0.18, 0.60] 0.223 0.000SCS 0.73 [0.48, 1.13] −0.005 0.156NML 1.42 [0.75, 2.67] −0.018 0.283Age 1.13 [0.70, 1.83] 0.000 0.624Single parent family 0.85 [0.30, 2.41] 0.003 0.766SCAS-c 0.89 [0.42, 1.94] 0.008 0.780SMFQ-c 1.06 [0.46, 2.45] −0.003 0.902

R2 = 0.315, p = 0.004Parents

DASS 1.53 [1.09, 2.17] 0.039 0.014CS-p 0.66 [0.45, 0.97] 0.045 0.033Age 1.26 [0.83, 1.91] 0.012 0.275SMFQ-p 0.81 [0.52, 1.26] 0.008 0.345SCAS-p 0.88 [0.63, 1.24] −0.004 0.468Single parent family 1.09 [0.43, 2.79] 0.002 0.858

R2 = 0.123, p = 0.184

ote: *p < .05, **p < .01, ***p < .001. SCAS = Spence Child Anxiety Scale; SMFQ = ShML = Nijmejgen Motivational List; DASS = Depression, Anxiety and Stress Scales; c

ound to differ significantly between the early and late dropoutsTable 1). When conducting multiple tests, the Holm modified Bon-erroni procedure was applied to control for an experiment-wiserror rate ̨ of .05 (Holm, 1979). Seven clinics participated in thetudy. The GCBT approach comprised 16 separate treatment groupshile children in the ICBT approach were grouped as one cluster

t each of the seven clinics, giving a total of 23 clusters. The designas therefore partially clustered, and all analyses were adjusted for

otential clustering effects (Baldwin, Bauer, Stice, & Rohde, 2011;auer, Sterba, & Hallfors, 2008). All analyses were run using Mplus

(Muthén & Muthén, 2011).Missing data at the item and measure level were examined using

he missing value analysis in SPSS 20 (IBM Statistics, Chicago, USA).issing data did not exceed 11% for any measure across all time

oints and informants, except for 12 children and three parentshere missing data level was higher (M = 18.4%). Missing data orig-

nated mainly from treatment dropouts, and to a less degree fromacking or incomplete measures from treatment completers. Asndicated by Little’s “Missing completely at random” test, missingata on the measure level occurred completely at random. Missingata were accommodated using full information maximum likeli-ood (FIML) missing data methodology (Wothke, 2000) in Mplus,hus a missing data point did not result in deletion of the partici-ant. Non-normality was evident in several variables. To account

or the non-normality present in the data, analyses were pursuedn Mplus with the MLR estimator shown to be robust to viola-ions of normality based on the Huber–White algorithm (Muthén

Muthén, 2011).

. Results

omparisons of completers and dropouts

Demographic, clinical, and treatment factors are presented inable 1 for the total sample, separate for completers and dropouts,nd separate for early and late dropouts. Twenty-six children14.4%) dropped out of the treatment. Of these, 15 (57.7%) droppedut early and 11 (42.3%) late in the treatment. Table 2 shows the uni-ariate associations among the clinical- and treatment variables.ignificant inter-correlations were found for several of the vari-bles. One should note that the child’s and the parent’s version of

predictor were only moderately inter-correlated (SCAS r = 0.26,FQ r = 0.34, CS r = 0.34), favoring the inclusion of both perspec-

ives. Child reported treatment credibility and self-concept wereignificantly correlated with dropout.

In the univariate regression analyses, there were no sig-ificant differences between completers and dropouts on anyf the demographic or diagnostic variables (Table 1). Further-ore, there were no significant differences between completers

ood and Feelings Questionnaire; CS = Credibility Scale; SCS = Self Concept Scale;; p = parent.

and dropouts regarding child- and parent-rated child anxiety ordepressive symptoms, or child pretreatment motivation. How-ever, dropouts rated the treatment credibility significantly lower( ̌ = −7.34, SE = 1.46, p < .001), and also rated their self-concept sig-nificantly lower ( ̌ = −4.81, SE = 1.89, p < .05). After correcting formultiple comparisons, only the association with treatment credi-bility remained significant.

Early and late dropouts differed significantly regarding childage ( ̌ = 1.04, SE = .48, p < .05) and parent treatment credibility( ̌ = −5.12, SE = 1.76, p < .01), with higher child age and lower parenttreatment credibility associated with late dropout. After correctingfor multiple comparisons, only the association with parent treat-ment credibility remained significant.

Predictors of dropout

Multivariate logistic regression analyses including all predic-tors were conducted to predict dropout. Separate analyses forchild-rated (age, single parent family, SCAS-c, SMFQ-c, CS-c, SCS,and NML) and parent-rated (age, single parent family, SCAS-p, SMFQ-p, CS-p, and DASS) measures were done. Results fromthe analyses are presented in Table 3. For child-rated measures,

Note. ORs and corresponding 95% CIs are given for 1SD change, except for Sin-gle parent family status. CS = Treatment Credibility Scale; SCS = Self Concept Scale;NML = Nijmejgen Motivational List; SCAS = Spence Child Anxiety Scale; SMFQ = ShortMood and Feelings Questionnaire; DASS = Depression, Anxiety and Stress Scale;c = child; p = parent.

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ariance in the overall model was significant only for child meas-res (R2 = 0.315, p = 004), and not for parent measures (R2 = 0.123,

> .05). To illustrate the strength of the association and the possiblelinical utility, an increase of 1 SD (6.6 points) on the child Credi-ility Scale indicated a 68% reduction in the odds of dropping outf treatment.

To assess predictors for early and late dropout, the same setsf child- and parent rated variables were included as predictors

n multinomial logistic regression analyses, conducted separatelyor child and parent measures with dropout phase as dependentariable. In the model including all seven child-rated variables,igher treatment credibility significantly reduced the odds of botharly (OR = 0.84, 95% CI [0.73, 0.97], p < .05) and late (OR = 0.85, 95%I [0.76, 0.95], p < .01) dropout. For parent-rated measures, higher

nternalizing symptoms score increased the odds for early dropoutOR = 1.03, 95% CI [1.01, 1.06], p = .02), whereas higher parent treat-

ent credibility reduced the odds for late dropout (OR = 0.83, 95%I [0.75, 0.93], p < .001).

When including the significant predictors obtained from thendividual child- and parent analyses (i.e., child- and parent ratedreatment credibility, and parent self-rated internalizing symp-oms) in a post-hoc logistic regression model, child rated treatmentredibility (OR = 0.83, 95% CI [0.78, 0.88], p < .001) and parent self-ated internalizing symptoms (OR = 1.04, 95% CI [1.02, 1.07], p < .01)emained significant predictors of overall dropout. The explainedariance in the overall model was significant (R2 = 0.382, p < .001).imilarly, in the multinomial regression analysis, child rated treat-ent credibility significantly predicted both early (OR = 0.79, 95%

I [0.67, 0.93], p < .01) and late (OR = 0.86, 95% CI [0.76, 0.97], p = .02)ropout, whereas parent self-rated internalizing symptoms sig-ificantly predicted early dropout (OR = 1.05, 95% CI [1.01, 1.10],

= .02).

nalyses on a subgroup of dropouts

To examine whether the results were affected by heterogene-ty in the dropout group, we performed supplementary analyses,xcluding those patients who dropped out due to improvement oras referred to other treatments (n = 8). The analyses were repeated

omparing the remaining dropouts (n = 18) to the treatment com-leters (n = 155), using the same set of selected predictors. Theattern of results was consistent with the primary analyses, and didot change the interpretation of the results – i.e., low child ratedreatment credibility and elevated levels of parent self-rated inter-alizing symptoms remained significant predictors of dropout. Theesults indicate that the heterogeneity in the dropout group causedy including all children who did not complete the treatment pro-ocol did not affect the analyses of potential predictors.

. Discussion

This study examined predictors of treatment dropout amonghildren participating in an effectiveness trial of CBT for anxietyisorders in community clinics. The observed dropout rate of 14.4%

s close to rates reported from two previous studies of predictorsf dropout in CBT efficacy trials for child anxiety disorders (Kendall

Sugarman, 1997; Pina et al., 2003), and considerably lower thanhe 51.3% reported from eclectic treatments of anxious childrenn a community clinic (Gonzalez et al., 2011). The low dropoutate in our trial is comparable to results from other studies usingime-limited and manualized interventions (de Haan et al., 2013),

nd may reflect important aspects of how the treatment programas organized. The limited duration and structured schedules of

reatment manuals may provide predictability for patients, andence increase motivation and ability to complete treatments (Pina

xiety Disorders 31 (2015) 1–10 7

et al., 2003). Furthermore, the therapists contacted families whodid not show up for appointments to reschedule, and this may haveencouraged and supported the continuation of treatment to a largerextent than typical for regular clinical practice. Another possibleexplanation for the low dropout rate could be that mental healthservices were free of charge.

Some salient differences between completers and dropoutsin pretreatment characteristics emerged. Low child- and parent-rated treatment credibility predicted overall dropout. Child-ratedtreatment credibility predicted dropout in both early and latephases of treatment, whereas parent-rated treatment credibilitypredicted dropout in the late phase. Child-rated treatment credi-bility accounted for a proportion of 22% of the explained variance intotal dropout odds in the regression analysis. Treatment credibilityusually refers to how treatment is perceived after the rationale forand contents of the treatment program have been explained, butbefore the main treatment has started (Greenberg et al., 2006). Itmay be moderated by therapist behavior and characteristics, as thiscan impact on how credible the therapist is perceived to be (Frank& Frank, 1993; Karver, Handelsman, Fields, & Bickman, 2005). Itis reasonable to assume that children who perceive the treatmentoffered as less credible, are less likely to engage in therapy and tocomplete it. This is in line with previous studies, reporting thattreatments perceived as of little relevance are associated withlower treatment adherence (de Haan et al., 2013; Kazdin, 2000;Kazdin et al., 1997). However, the majority of studies investigatingthis relationship have been conducted on children with externaliz-ing disorders. The present results suggest that this relationship mayalso be valid for children with anxiety disorders. This highlightsthe importance of addressing the children’s attitudes towards thetreatment offered, and the perceived relevance to the problem athand, since it is possible to influence these factors either by chang-ing aspects of the treatment and improve the child’s and his/herparents understanding of the treatment (Kazdin et al., 1997). Parentperceived treatment credibility and expectancy have been found topredict treatment adherence for children with externalizing disor-ders (Nock, Ferriter, & Holmberg, 2007). In our study both children’sand parents’ report of treatment credibility contribute to the pre-diction of dropout, suggesting that focusing on ways to increaseboth child- and parent perceived treatment credibility could pre-vent treatment dropout.

Parents’ elevated levels of self-rated internalizing symptomspredicted dropout, particularly in the early phase of treatment. Thisis in line with findings that families experiencing more stressorsand where parent have more internalizing problems are at greaterrisk for dropping out from treatment (de Haan et al., 2013; Kazdin,2000). The present findings also indicate that it is important toaddress parental symptoms and distress early in treatment. Par-ticipating in treatment is usually a demanding process, both forpatients and caregivers, and may increase the level of stress in thefamily (Kazdin, 1996). The increased level of stress may exceed thecapacities of already challenged parents. Identifying parental riskfactors for dropout, and addressing them throughout the treatmentperiod may be important to improve treatment adherence. Overall,the predictors identified in the separate child- and parent analyseswere robust to post-hoc analyses.

In the present study children who dropped out from treat-ment did not differ significantly from completers with respect todemographic and most of the clinical factors. Dropouts reportedsimilar levels of anxiety and depressive symptoms as did treat-ment completers, and single parent family status or comorbidityrates did not differ between the two groups. These findings are

in line with efficacy trials of childhood anxiety disorders repor-ting no (Pina et al., 2003) or only few (Kendall & Sugarman, 1997)significant differences between completers and dropouts. In an out-patient community clinic sample of anxious youth, higher levels

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f caregiver-rated youth depressive symptoms were found amongropouts (Gonzalez et al., 2011). This finding may be explained byhe fact that Gonzalez et al. (2011) used a more clinically diverseample than in the present study, with only 36.5% of the youthample having a primary anxiety disorder.

We found that dropouts rated their self-concept lower thanreatment completers. Also, increasing age was associated withigher risk of dropout in the late treatment phase. These differencesere no longer significant after controlling for multiple testing.

ased on the previous research we could hypothesize, that childrenith lower self-concept experience themselves as less competent

o engage in therapy and to achieve behavior changes, and thathis puts them at risk of dropping out from treatment (Bong &kaalvik, 2003; Strecher, McEvoy DeVellis, Becker, & Rosenstock,986). However, this needs to be investigated further in futuretudies.

Contrary to our expectations, child pretreatment motivation didot differ between completers and dropouts. This is somewhat puz-ling, as treatment credibility and treatment motivation is assumedo be related. However, whereas motivation was assessed prioro the first treatment session, treatment credibility was assessedt the end of the first treatment session, after the rationale forreatment had been presented. This difference may help explainhy treatment credibility, but not pretreatment motivation, dif-

ered significantly between completers and dropouts. One shouldote that pretreatment motivation and treatment credibility werencorrelated in our study (r = .001, see Table 2), and probably rep-esents separate constructs, as argued by Greenberg et al. (2006).hus, a patient may be highly motivated for treatment but stillerceive the therapy offered as unconvincing or not relevant.

In the multivariate logistic regression analyses (Table 3), theonsignificant differences may also be due to insufficient power, or

ack of variability in our sample population. The variables includedn the analysis were identified based on an empirical or theoreticalelationship with dropout, or from the univariate analyses in ourample. Prospective studies on predictors for dropout, conducted inommunity settings with a diverse population, may further clarifyhat influences on dropout risk.

The present study has some limitations that warrant consid-ration. First, there were only 26 dropouts, which also meant theumber of dropouts in the early and late phase of treatment was

ow. Although we are pleased that not more children droppedut, small sample sizes is a recurrent problem when examiningropout, and our sample size is comparable with previous trialsxamining treatment dropout (Kendall & Sugarman, 1997; Pinat al., 2003). In addition, treatment credibility could not be assessedor six of the dropouts (23%), who dropped out prior to the firstreatment session. The missing data were, however, handled by rec-mmended methods (FIML). Also, in the present study the groupf dropouts was heterogeneous, with rather different reasons forropout. Although we performed additional analyses on a subgroupf dropouts, the low numbers did not allow for separate analysesor each category. Second, reasons for treatment dropout were notssessed with a standardized instrument, but based on informationoted by the clinic staff. Although this may have introduced some

nformation bias, especially if reasons for dropout were related toherapist behavior or alliance, the reasons reported in this studyorrespond to those reported previously (Pekarik, 1983). Third, sev-ral of the predictor variables were correlated with each other, andetween child and parent informants. However, all correlationsere relatively low (<.50). Fourth, there is no consensus in the field

n how to define early and late dropout in manualized treatment

rograms, and our definition based on treatment modules and mid-oint of treatment may be challenged. Fifth, we did not considerther treatment factors besides treatment credibility and motiva-ion that could have influenced dropout. Treatment expectancy, a

xiety Disorders 31 (2015) 1–10

construct closely related to treatment credibility, has been asso-ciated with treatment completion (Greenberg et al., 2006; Nock& Kazdin, 2001), as has therapeutic alliance, i.e., the collaborativebond between patient and therapist (Shirk & Karver, 2003). Finally,ethnic minority enrollment was too low (1.6%) to allow for analysesof ethnicity related to dropout. The small number of non-Caucasianparticipants is, however, typical for most Norwegian communityclinics.

Although a somewhat lower rate of treatment dropout wasfound in this study compared to other child anxiety dropout stud-ies, dropout from therapy is a significant problem that needs to beaddressed. In terms of clinical implications of the results, the thera-pists should focus on examining and targeting perceived treatmentcredibility and parental internalizing symptoms early in treat-ment in order to help children continue in treatment. Therapistsshould target at-risk individuals, and employ pre- and in-treatmentinterventions to mitigate the risk of dropout. Treatment credibil-ity may be improved via psychoeducation (information leaflets,information videotapes; Shuman & Shapiro, 2002), and treatmentengagement strategies from motivational interviewing could beused to enhance clients’ motivation for change (Barrett et al.,2008). A limited number of parent sessions could be offered to par-ents with elevated levels internalizing symptoms, or they may bereferred for treatment for their own. By paying attention to thesefactors and making adaptions where needed, clinicians may be ableto reduce rates of treatment noncompletion in their work withanxious children.

4. Conclusions

The present study identified predictors of treatment dropoutin children with anxiety disorders that may be accessible forinterventions to promote treatment continuation. Low child- andparent-rated treatment credibility, and high parent self-rated inter-nalizing symptoms predicted dropout from CBT treatment for childanxiety disorders delivered in community clinics. Therapists shouldbe aware of the importance of treatment credibility and parentemotional well being for treatment adherence, and seek ways toexamine and address these factors early in treatment.

Acknowledgements

The study received support from the Western Norway RegionalHealth Authority, through project number 911366 and 911253.The study received additional financial support from the MeltzerResearch Foundation at the University of Bergen, Norway, fromJosef and Haldis Andresenı́s Foundation, from Solveig and JohanP. Sommerı́s Foundation for promotion of research on clinicalpsychiatry, and from Maja and John Nilsenı́s Foundation. We aregrateful to Professor Paula Barrett for contribution to CBT training,to Professor Robert Goodman for contribution to planning and datacollection, and also to Professor Torbjørn Torsheim for contributionto data handling. We would like to thank clinicians, administra-tive staff and management at the participating community mentalhealth clinics. Finally, we want to express our deep gratitude tochildren and parents for participation in the study.

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