Alleviating Specific Phobias Experienced by Children Trial (ASPECT)

The challenge

A specific phobia is an intense, long-term fear of a situation or object and is associated with anxiety, distress, and avoidance. 5%–10% of children and young people (CYP) experience specific phobias that impact daily functioning. Cognitive Behaviour Therapy (CBT) is the current recommended treatment but has limitations due to the time and costs to deliver. 

One Session Treatment (OST) is a briefer alternative incorporating CBT principles into an assessment session, and a single 3-hour session. It uses many of the same techniques as CBT (e.g. graduated exposure therapy, participant modelling, reinforcement, psychoeducation, cognitive
challenges and skills training), but takes a more condensed and intensive approach. OST has demonstrated efficacy in small studies but has not previously been compared to the current recommended treatment – multi-session CBT. 

The Alleviating Specific Phobias Experienced by Children Trial (ASPECT) investigated the non-inferiority of OST compared to multi-session CBT for treating specific phobias in CYP.    

The research

ASPECT was a randomised two-arm, multicentre, non-inferiority trial – looking at whether OST is as good as CBT for treating simple phobias in CYP aged 7-16 years. It ran in 12 NHS trusts comprising 26 Child & Adolescent Mental Health Services (CAMHS), three third-sector/voluntary services and one university-based CYP’s well-being service. 

We recruited 268 CYP to the trial, half received OST and half received CBT for their simple phobia. We saw CYP were scared of lots of
different types of things including being sick, dogs, having injections,
costume characters, insects etc.

Before the therapy was given, we tested how scared the CYP were of their phobia using the Behavioural Avoidance Task (BAT) – which measures how close someone can get to the thing they are scared of. We also did this 6-months after the treatment.

We also interviewed some of the parents, children and therapists about OST to find out what they thought of it and collected data on costs to health and social care.

The study was sponsored and led by Leeds and York Partnership NHS Foundation Trust (LYPFT), in collaboration with the University of Sheffield Clinical Trials Research Unit (CTRU), which coordinated the study nationally.

The results

ASPECT showed that OST for children and young people with specific phobias is as clinically effective as multisession CBT and is highly likely to be a cost-saving alternative in UK-based child mental health treatment centres.

We found three main things in the research: 

OST was as good as CBT in helping children and young people with Specific Phobias.  BAT scores at the 6-month follow-up were similar for OST and CBT, with a larger number of participants achieving 10 steps at 6 months than at baseline in both treatment groups, showing improvement in phobia overall.  The treatments appear comparable for the secondary outcomes. Some point estimates were slightly in favour of CBT and others were slightly in favour of OST; none was statistically significant.

Children and young people, their parents/guardians and therapists found OST to be a helpful treatment for them and their needs. 
In total, 27 participants and 27 parents/guardians were interviewed by a research assistant following their 6-month follow-up appointment. In addition, 16 clinicians participated in a telephone interview. The interviews demonstrated a good level of acceptability of and satisfaction with OST from the perspectives of participants, parents/guardians and clinicians.
The core components of OST that were identified to influence the treatment process and satisfaction were: child readiness, therapist competency and collaboration. Several clinical challenges were identified during interviews, such as the current provision of phobia treatment, access to phobic stimuli and scheduling longer sessions.

OST was even a bit cheaper treatment to deliver than CBT.  The health economic analysis showed that, compared with CBT, OST marginally decreased the mean service use costs and increased the mean QALYs at 6 months’ follow-up; however, reduced resource use and improved utility compared with baseline were observed in both groups.

During the trial, we also found that the treatment for CYP with simple phobias in child mental health centres is inconsistent and limited in some areas, with a number of sites approached to take part saying the did not see CYP with simple phobias. 

Impact

The NIHR funded some enhanced dissemination work for ASPECT, with Lina Gega undertaking training events for therapists, and further dissemination of the findings.

Publications

• Wright, B., Tindall, L., Scott, A. J., Lee, E., Cooper, C., Biggs, K., ... & Marshall, D. (2022). One session treatment (OST) is equivalent to multi‐session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): results from a national non‐inferiority randomized controlled trial. Journal of Child Psychology and Psychiatry. 
• Hayward, E., Solaiman, K., Bee, P., Barr, A., Edwards, H., Lomas, J., ... & Wright, B. (2022). One-session treatment for specific phobias: Barriers, facilitators and acceptability as perceived by children & young people, parents, and clinicians. PloS one, 17(9), e0274424.
• Wang, H., Wright, B., Tindall, L., Cooper, C., Biggs, K., Lee, E., Teare, M.D., Gega, L. et al. (2022).   Cost and effectiveness of one session treatment (OST) for children and young people with specific phobias compared to multi-session cognitive behavioural therapy (CBT): results from a randomised controlled trial.  BMC Psychiatry, 22, 547.
• Tindall, L., Scott, A.J., Biggs, K., Hayward, E., Wilson, J., Cooper, C., Hargate, R., Wright, B. & Gega, L.  (2022). The Alleviating Specific Phobias in Children Trial: Challenges and solutions to implementing a randomised controlled trial in clinical services 

Project team

Participating sites

Funder

This project is funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number This project is funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 15/38/04). Any views or opinions expressed are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.). Any views or opinions expressed are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Sponsor

ASPECT is sponsored by the Leeds and York Partnership NHS Trust.