Introduction

Despite clinical anxiety being one of the most com-mon mental health conditions in adolescents [5] andthat many efficacious cognitive behavioural therapy(CBT) programs have been developed (reviews, [3,10]), only one in four young people receive profes-sional help for this problem [18]. Identified barrierswith traditional treatments and services include con-fidentiality, stigma, cost, geographic or social isola-tion, content appropriateness, format of engagement,and waiting time [2, 28].

In their review of 13 studies involving 498 ado-lescents and children, James et al. [10] reported thatCBT was effective in 56% of cases and that the effectswere durable. Individual, group, or parental/family

formats all produced similar outcomes. However,older adolescents were under-represented in the re-view and clinical experience suggests that anxiety inthis group presents additional treatment challengesdue to difficulties with engagement and motivation atthis developmental stage.

More ‘‘creative and innovative’’ approaches totreatment are worth exploring [9], and one promisingformat is computer-based treatment [1, 4, 12, 19].Advantages include cost effectiveness (reduced ther-apist time), time and travel convenience, engagingcontent, potential to reach those reluctant to makeface-to-face contact, and broader service dissemina-tion, particularly to rural participants. Disadvantagesinclude extensive time and resources needed todevelop such programs, difficulty monitoring pro-gram use, potential technical problems, and lack of

M.J. CunninghamV.M. WuthrichR.M. RapeeH.J. LynehamC.A. SchnieringJ.L. Hudson

The Cool Teens CD-ROM for anxietydisorders in adolescents

A pilot case series

Accepted: 8 April 2008Published online: 18 June 2008

j Abstract Five adolescents re-ceived a multimedia CD-ROMcontaining a self-help treatmentprogram for young people with ananxiety disorder. Participants usedthe 8-module Cool Teens CD-ROMover a 12-week period on a homecomputer. Every 2 weeks, theyreceived a brief telephone callfrom a clinical psychologist tomonitor symptoms and progressand to discuss any problems withunderstanding content or imple-menting techniques. Based onstructured interviews, two partici-pants (40%) no longer met diag-nostic criteria (self-report ADIS)for at least one clinical anxietydisorder immediately following

treatment and these same partici-pants no longer met diagnosticcriteria for any clinical anxietydisorder at 3-month follow-up.Two other participants failed tomake gains based on diagnosticcriteria, but showed improvementin anxiety symptoms for one mainfear. Participants were generallysatisfied with the multimediacontent, the modules, and thedelivery format of the program.

j Key words anxiety disorders –adolescents – computer-basedCBT – multimedia –self-help

BRIEF REPORTEur Child Adolesc Psychiatry (2009)18:125–129 DOI 10.1007/s00787-008-0703-y

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M.J. Cunningham (&)V.M. Wuthrich Æ R.M. RapeeH.J. Lyneham Æ C.A. SchnieringJ.L. HudsonCentre for Emotional HealthDepartment of PsychologyMacquarie UniversityNSW 2109 Sydney, AustraliaE-Mail: mjjcunning@hotmail.com

suitability for some clients. There are no existingpublished studies on computer-based therapy pro-grams for adolescents with anxiety.

A multidisciplinary team at Macquarie University’sCentre for Emotional Health has recently producedthe Cool Teens CD-ROM, a home-based therapy op-tion for anxious adolescents [6, 8], allowing individ-uals to move at a pace and intensity to suit theirspecific problems. Content focuses on social phobia(SP) and generalized anxiety disorder (GAD), but alsocovers separation anxiety disorder (SAD), specificphobias (SpP), and obsessive-compulsive disorder(OCD). Feedback to a prototype rated the interactiveformat of this program positively, and many adoles-cents reported it acceptable as a therapy option [7].This paper presents a case series on early users of theCool Teens CD-ROM.

Methods

j Participants

Four females (aged 14–16 years) and 1 male (aged16 years) were recruited from successive parentalreferrals to the Macquarie University Anxiety Re-search Unit (MUARU), Sydney, Australia betweenMarch and May 2006. Inclusion criteria were: aprincipal diagnosis of an anxiety disorder, age be-tween 14 and 18 years, and access to a home com-puter. Exclusion criteria included problems requiringimmediate attention (e.g., suicidal ideation, self-harm,abuse, psychosis) and significant learning difficulties.Participants were required to stabilise current medi-cation and to not engage in other active therapyduring the study period. Four participants had aprincipal diagnosis of GAD and one had SAD. Manyhad additional anxiety diagnoses. The research wasapproved by the Macquarie University Ethics ReviewCommittee and each adolescent and a parent gavewritten consent.

j Measures

Pre- and post-treatment diagnoses and outcomeswere clinically assessed using the Anxiety DisordersInterview Schedule for Children (ADIS-C-IV) [24].This provides a DSM-IV diagnosis and is reliable forchild and adolescent anxiety disorders (j = 0.8–1.0)[15]. ADIS-IV ratings are reported as a clinicianseverity rating (CSR) on a 9-point scale (0 = not at alldisturbing/disabling; 8 = very severely disturbing/disabling; a rating under 4 is sub-clinical), based onadolescent report, parent report, and therapist’scombined interpretation. The structured interview

was conducted face-to-face for participants in theSydney area and over the telephone for participantsoutside the Sydney area. All post-treatment ADISassessments were conducted over the telephone.Previous investigations have demonstrated that tele-phone administration has high validity [13].

Pre- and post-treatment anxiety symptoms weremeasured using the Spence Children’s Anxiety Scale(SCAS) [26, 27]. This 38-item measure assesses bothadolescent (SCAS-C) and parent (SCAS-P) reports ofsymptoms, closely corresponding to those in theDSM-IV. It has good psychometric properties withrespect to reliability and validity. Negative beliefswere assessed using the Children’s AutomaticThoughts Scale (CATS) [22], a 40-item self-reportmeasure designed to assess negative self-statements.This scale has been shown to have good discriminantvalidity for each of the subscales across childhooddisorders, including anxiety, and good convergentvalidity with related anxiety scales [21, 23]. During atherapist contact telephone call every 2 weeks, ashortened version of the SCAS-C and an AnxietySymptom Tracking Measure designed to assess eachparticipant’s self-identified main fear were adminis-tered. Participant satisfaction was measured using a10-question adapted Barriers to Treatment Partici-pation Scale [11] and a Preferences and AttitudesQuestionnaire.

j Treatment

The Cool Teens CD-ROM is a multimedia programincorporating text, graphics, video, voiceover, andgraphics. It comprises 8 modules covering the fol-lowing therapeutic components: Module 1—Psycho-education, Module 2—Goal Setting, Modules 3 and5—Cognitive Re-structuring, Modules 4 and6—Exposure, Module 7—Coping Skills, and Module8—Maintenance. Each module takes 15–30 min tocomplete and contains information, interactive exer-cises, hypothetical scenarios, case studies, and prac-tice tasks [6].

The content of the CD-ROM modules is based onmaterial from the well-established Cool Kids anxietyprogram that delivers these same cognitive behaviouralskills through 10-week therapist-guided group therapy[16]. This program has been shown to be efficaciousin clinical settings, school settings, telephone baseddelivery, and bibliotherapy format [14, 17, 20].

In the current study, use of the CD-ROM wassupported by some therapist contact. A clinical psy-chologist made a telephone call to each participantevery 2 weeks to ask a set of questions regardingprogress and understanding of material. The purposes ofthe calls were to provide motivation, keep participants

126 European Child & Adolescent Psychiatry (2009) Vol. 18, No. 2� Steinkopff Verlag 2008

moving through modules at a good pace, and clarifyany issues regarding the content. Minimal therapeuticassistance was included if requested. The adolescentwas reminded of the clinic’s contact details if theyneed help with strong negative feelings.

j Procedures

Potential participants were screened briefly to ascer-tain suitability for study inclusion and were providedwith information and consent forms. To assess thediagnostic status of participants, ADIS-IV interviewswere conducted by a clinical psychologist. Pre-treat-ment questionnaires (SCAS-C, SCAS-P, & CATS) weresent by mail for completion and a pre-paid envelopewas provided for their return.

Once questionnaires and consent forms were re-ceived, participants were sent the Cool Teens CD-ROMfor use over an initial period of 12 weeks. They wereasked to work through the self-help program andwere informed they would receive a brief call from apsychologist every 2 weeks to assess progress. Theywere told they would be re-assessed after 12 weeksand should aim to complete all of the modules bythen. Participants were provided with contact detailsfor the clinic to give them a sense of connection andto provide access to professional help in case of anemergency.

After 12 weeks of therapy, each participant com-pleted a post-treatment telephone ADIS interviewand returned Barriers to Treatment Scale and UserPreferences and Attitudes questionnaires. Each par-ticipant received $30.00 to compensate for time spenton the research. Participants were encouraged tocontinue using the CD-ROM for a further 12 weeks,and were told that the same re-assessment andpayment procedure would be carried out after thatfollow-up period.

Results

Table 1 shows the pre- and post-treatment and 3-month follow-up scores for the clinical ADIS inter-view. Four participants completed at least six of theeight modules within the 12 weeks. The length of thescheduled telephone support calls ranged from 5–20 min per session (mean = 13.5, SD = 6.82).

Participant 1, a 15-year old female with GAD and 3co-morbid anxieties, completed all 8 modules withinthe initial treatment period and reported regularconsistent use of the program. Her most positive gainwas a large improvement in anxiety rating for hermain fear as measured by the Anxiety SymptomTracking Measure. Her parent SCAS score demon-strated some reduction in anxiety but no changes inADIS diagnosis or severity were observed.

Participant 2, a 16-year old female with GAD and aco-morbid SpP, completed 6 modules. At post-treat-ment she improved greatly on the self-reported anx-iety rating for her main fear. While her ADIS-C ratingfor GAD was reduced from 6 to 4, this improvementwas not supported by ADIS-P and self-report mea-sures data. In addition, she now reported social anx-iety fears that met criteria for SP, despite havingdenied their presence at pre-assessment. At follow-up,her ADIS-C rating was slightly reduced from the pre-treatment level, and some gains were made in her self-reported SCAS and CATS scores.

Participant 3, a 14-year old female with SAD alongwith secondary GAD and a SpP, completed 7 modules.Post-treatment, her ADIS rating for SAD showedslight improvement and she reported that she was‘‘just getting to’’ the major steps in her exposurehierarchy. Severity ratings for her secondary diagno-ses had both reduced to subclinical levels based oncombined ADIS data. At follow-up, her ADIS-C ratingfor SAD was one and the ADIS-P and combined rat-ings for her three anxiety disorders were at subclinical

Table 1 Pre, post, and follow-up ADIS severity ratings for their primary diagnosis only

Measure Case 1 Case 2 Case 3 Case 4 Case 5F, 15, GAD F, 16, GAD F, 14, SAD F, 15, GAD M, 16, GAD

ADIS (0–8) (adolescent only report) Pre 6 6 6 6 6Post 6 4 5 2 2Follow up 6 5 1 – 0

ADIS (0–8) (parent only report) Pre 7 6 6 6 6Post 6 7 6 2 –Follow up 7 7 3 – 6

ADIS (0–8) (adolescent & parent combined report) Pre 7 6 6 6 6Post 6 7 5 2 2Follow up 7 7 3 – 5

Total # Anxiety Diagnoses (combined report) Pre 5 (2 SpP) 2 3 5 (4 SpP) 1Post 5 (2 SpP) 3 1 1 0Follow up 6 (3 SpP) 3 0 – 0

ADIS-C anxiety disorders interview schedule for Children (DSM-IV); ADIS-P ADIS-parent version; ADIS combined clinician rating from child and parent reports

M.J. Cunningham et al. 127The Cool Teens CD-ROM pilot case series

levels. Her parental SCAS reports were much im-proved.

Participant 4, a 15-year old female with GAD andfour co-morbid SpPs, completed two modules beforediscontinuing treatment after week 4 because she re-ported she no longer had anxiety and required nofurther therapy. This participant and her mother bothreported that the early CD content, especially thepsychoeducation module, had helped her discuss andwork on her problems more with her family. Her post-treatment ratings (ADIS-C and ADIS-P) were reducedto subclinical levels for GAD and all but one SpP.

Participant 5, a 16-year old male with GAD, com-pleted all 8 modules and showed an improvement to asubclinical level as shown by an ADIS-C anxiety rat-ing reduction from 6 to 2. This finding was supportedby some gains in SCAS and CATS scores and by thepaternal SCAS-P scores. At follow-up, his ADIS-Canxiety rating remained subclinical and was evenfurther reduced (to 0).

All program modules and media components wererated positively. Some barriers were identified, with‘‘finding time’’ rated as the greatest difficulty. Specificlikes and dislikes were reported and suggestions forimprovements were made, but seemed to reflect per-sonal preferences rather than recurring programweaknesses.

Discussion

The pilot research reported here was a case series thatevaluated several clinical outcomes with five adoles-cents who used the Cool Teens CD-ROM for thetreatment of diagnosed anxiety disorders over a12-week therapy period with a 3-month follow-up.Post-treatment assessment showed 2 participants(40%) had anxiety severity ratings that were reducedto a subclinical level for at least 1 clinical anxiety

disorder. At 3-month follow-up, these two partici-pants no longer met diagnostic criteria for any clinicalanxiety disorder. All of the adolescents were generallysatisfied with the multimedia content, modules, anddelivery format of the program.

The adolescent who had the greatest overallimprovement was the only one who had no secondarydiagnoses. The participant who had the next bestoverall gains had two secondary diagnoses but herprimary problem was SAD rather than a broader dis-order. In contrast, the participants who had a largernumber of secondary diagnoses and more complexclinical presentations made the least overall improve-ments. This is consistent with a previous study show-ing that higher levels of pre-treatment symptomspredicted poorer post-treatment outcomes [25].

Not all measures indicated improvements. Indeed,participant scores on some scales increased from pre-to post-treatment. One possibility is that the programincreased adolescents’ awareness of their anxieties. It isimportant to note that only two of the five participantscompleted all eight modules within the 12-week time-frame, mainly due to not being able to ‘‘find time’’.

The overall level of effectiveness from this pilotevaluation of the Cool Teens CD-ROM, with its mixedfindings for various participants, may suggest twobroad possibilities. First, there may be ways to im-prove the program by enhancing the CD-ROM’s var-ious components with the goal of increasing usercompliance, motivation, and benefit. Second, this self-help format may never be expected to do as well astherapist-led treatment in terms of clinical efficacy.Based on the positive user feedback data, this formatalso has other advantages such as increased accessi-bility and acceptability for this rather difficult to en-gage population.

j Acknowledgments Vice Chancellor’s Development Fund (Mac-quarie University) and Australian Rotary Health Research Fund.

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