HANDS-ON: a Personalized, Brief and Intensive Exposure-based Intervention for Youth With Persistent Anxiety or OCD

A substantial part of children/adolescents with anxiety or obsessive-compulsive disorder (AD/OCD) do not profit substantially from first-choice treatment (i.e., cognitive behavioral therapy; CBT). For them, no evidence-based treatment is available. The aim of this project is to evaluate and optimize a newly-developed personalized, short, and intensive exposure-based intervention, 'HANDS-ON', for 'treatment non-responders'. Collaboration with children, parents and teachers, guided exposure in a child's natural environment, personalized treatment goals and meaning/motivation are central principles.

Methods: A multiple baseline single-case experimental design is used (qualitative and quantitative). Participants are children/adolescents (10-18 years; N=12) with an AD/OCD diagnosis for whom standard CBT did not lead to sufficient improvement. Children and parents are asked to complete questionnaires before, during, and after the treatment. Children, parents, and school professionals will be asked to participate in qualitative interviews to evaluate their experiences with the HANDS-ON treatment program.

BACKGROUND Nearly half of children and adolescents with anxiety or obsessive-compulsive disorders do not reach remission after first-choice treatment (cognitive behavioral therapy; CBT) and 10-25% discontinue treatment prematurely. For them, no evidence-based treatment is available. They may have severe symptoms with a huge impact on daily functioning, quality of life, family life, and society. These youth are at risk of developmental delays, among others due to school refusal. They often receive time-consuming, expensive treatment without evidence of effectiveness.

OBJECTIVES The aim of this project is to evaluate and optimize a newly-developed treatment for this group. This treatment, 'HANDS-ON', is innovative, short and intensive, based on scientific research and insights from clinical practice. Collaboration with children, parents and teachers, guided exposure in a child's natural environment, personalized treatment goals and meaning/motivation are central principles.

Our research questions are:

1. Quantitative: What are (within-subjects) effects of HANDS-ON on personalized goal attainment, anxiety/OCD severity, and functioning in youth with persistent AD/OCD?
2. Qualitative: What are the experiences, facilitators and barriers of HANDS-ON from a child, parent, school professional and therapist perspective?

The results of this study will be used to improve HANDS-ON, with the aim to further investigate its effectiveness in a randomised controlled trial as a next step.

METHOD Participants are 12 children/adolescents with persistent anxiety- or obsessive-compulsive symptoms (treatment non-responders). Inclusion criteria: a) age 10-18 years; b) diagnosis of anxiety disorder or obsessive-compulsive disorder (DSM-5); c) non-response to previous CBT (CBT with insufficient effect). Co-morbid diagnoses are allowed except for those interfering with safety or warranting immediate treatment (e.g., acute suicidality or psychosis).

Design: multiple baseline single-case experimental design. Participants will be randomised to one of four baseline periods (2.5-4 weeks), followed by HANDS-ON (9 weeks) and follow-up (4 weeks). Progress on personalized treatment goals (primary outcome) and on symptoms (impairment and avoidance, secondary outcome) will be measured daily. Other outcomes will be measured at baseline (T0), start HANDS-ON (T1, subset), after HANDS-ON (T2), and at follow-up (T3). Semi-structured interviews (qualitative evaluation) will be conducted with the youth, their parents, school professionals, and therapists (post-treatment).

Analyses: The primary outcome will be analysed using randomisation tests and combined using meta-analytic analyses. Descriptive analyses and tests for repeated measures will be used to analyse secondary outcomes. Qualitative interviews will be recorded and analysed using thematic text analysis.

Eligibility Criteria:
Inclusion Criteria:

* Age between 10-18 years old;
* Meeting DSM-5 criteria for an anxiety disorder/OCD, based on a semi-structured interview (SCID-5 Jr; \[12\]) and clinical judgement of an experienced and authorized clinician;
* Non-responder to previous CBT (insufficient benefits from previous CBT for AD/OCD).

Comorbid diagnoses are allowed except for those interfering with safety or warranting immediate treatment, e.g., acute suicidality or psychosis.

Exclusion Criteria:

* Severe psychiatric symptoms other than anxiety/OCD interfering with safety or warranting immediate intervention, e.g. psychosis or acute suicidality.