Minimal Therapist-Assisted Cognitive–Behavioral Therapy Interventions in Stepped Care for Childhood Anxiety Alison Salloum University of South Florida New effective, efficient, and accessible service delivery methods for cognitive– behavioral therapies for pediatric anxiety disorders are needed. Many anxious children do not receive needed treatment because of barriers such as limited availability of trained practitioners, costs of treatment, and time. A cognitive– behavioral therapy (CBT) stepped care approach that “steps up” care as needed from less intensive therapies with minimal therapist assistance to therapist-directed treatment may address barriers and provide more accessibility to treatment. A stepped care approach does not necessarily mean that traditional weekly face-to-face therapy sessions will not be needed. However, different service delivery methods that begin with CBT minimal therapist-assisted interventions may be a first line of treatment because not all children may need the full treatment package. This article provides an overview of the current research on CBT minimal therapist-assisted interventions (i.e., modified CBT protocols, computer-based therapy, bibliotherapy, telephone-based therapy, group treatment, and pharmacology) and information on how these first-line treatments may be incorporated into a stepped care model. Minimal therapist-assisted interventions within a stepped care model are in the early stages of develop- ment, although there is evidence that these types of treatment may be a viable first step to treating pediatric anxiety disorders. More research on minimal therapist-assisted interventions within stepped care models is needed, and challenges associated with disseminating and implementing stepped care need to be addressed. Keywords: children and adolescents, anxiety, minimal therapist-assisted interventions, stepped care, cognitive– behavioral therapy Anxiety disorders are among the most common psychiatric disor- ders in children and adolescents (Cartwright-Hatton, McNicol, & Doubleday, 2006). In a study by Kessler et al. (2005), the lifetime prevalence rate for anxiety disorders was 28.8%, with the median age of onset being 11. Although large-scale epidemiology studies on all childhood anxiety disorders are limited, the following prev- alence estimates have been found: 10% for specific phobia; 6.8% for social phobia; 3.2% for generalized anxiety disorder, based on 1-year prevalence rates; 1%– 4% for obsessive compulsive disor- der; 4%–5% for separation anxiety disorder; 1%–5% for panic disorder; and 1%–14% for posttraumatic stress disorder, based on lifetime prevalence rates (reviewed in Keeley & Storch, 2009). Only a small proportion of children with anxiety disorders receive treatment (Essau, Conradt, & Petermann, 2002) despite mounting evidence of the effectiveness of cognitive– behavioral therapy (CBT) in treating childhood anxiety (Barrett, Farrell, Pina, Peris, & Piacentini, 2008; Bodden et al., 2008; Freeman et al., 2009; Silverman, Ortiz, et al., 2008; Silverman, Pina, & Viswesvaran, 2008). In light of the high prevalence rates, there are not enough trained clinicians to provide evidence-based practices for children with anxiety disorders (Vos et al., 2005). Therefore, new ap- proaches that use CBT with minimal therapist assistance as a first line of treatment within a stepped care model are being developed and tested to provide effective, efficient, and accessible ap- proaches to providing psychological intervention. Stepped care interventions are designed to maximize resources by providing lower intensity and less costly approaches as a first line treatment while stepping up care to address individualized client needs for those who require additional treatment (Bower & Gilbody, 2005; Haaga, 2000). Stepped care may increase the availability of resources to meet the demands that traditional therapist-directed face-to-face treatment cannot meet (Bower & Gilbody, 2005; Mataix-Cols & Marks, 2006). Although the imple- mentation of evidence-based practices in community settings is still limited (Kendall & Choudhury, 2003), stepped care allows trained clinicians to provide evidence-based practices to more children by using less therapist time. Stepped care provides an alternative approach for clients who have difficulty scheduling weekly clinic-based sessions because of issues such as transpor- tation, child care needs, or work demands or because they live in rural areas where therapists may not be available. Stepped care approaches recognize that not all individuals need the full package of weekly therapist-directed treatments. ALISON SALLOUM received her PhD from Tulane University. She is an assistant professor in the School of Social Work and has a joint appointment in the Department of Pediatrics at the University of South Florida. Her research interests include childhood mental health, with a specific focus on effective psychosocial interven- tions for children and families exposed to various types of trau- matic events. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Alison Salloum, School of Social Work, University of South Florida, 4202 East Fowler Avenue, MGY 132, Tampa, FL 33620. E-mail: asalloum@bcs.usf.edu Professional Psychology: Research and Practice © 2010 American Psychological Association 2010, Vol. 41, No. 1, 41– 47 0735-7028/10/$12.00 DOI: 10.1037/a0018330 41 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.