# Developing a primary care-based cognitive behavioral intervention for anxiety in children through a participatory approach: a qualitative study

## TL;DR

This study developed a primary care-friendly CBT intervention for children with anxiety using input from parents, therapists, and experts.

## Contribution

A participatory approach was used to create a primary care-adapted CBT protocol for children's anxiety.

## Key findings

- The intervention, Step by Step, uses a stepped-care model with group and individual sessions.
- Feedback from children and parents highlighted acceptance, feasibility challenges, and appropriateness of the approach.
- The protocol will be refined and tested in larger clinical trials.

## Abstract

Cognitive behavioral therapy (CBT) is an effective treatment for childhood anxiety, but CBT protocols suited for primary care are lacking, which limits accessibility. This study aimed to develop a CBT intervention for children aged 7–12 years with mild to moderate anxiety suitable for Swedish primary care.

A participatory design approach was used, including workshops and interviews with parents (n = 6), therapists (n = 12), managers (n = 3), and CBT experts (n = 3). Following development of a preliminary CBT protocol, children (n = 4) and their parents piloted the intervention. Subsequent interviews with children, parents, and therapists explored treatment experiences and informed further refinement.

The developed intervention, Step by Step, followed a stepped-care model comprising two steps: Step 1 (four group sessions and one individual session) and Step 2 (three additional individual sessions if needed). Interviews with children, parents, and therapists piloting the intervention resulted in three themes with corresponding subthemes: (a) acceptance - sense of not being alone; appreciation of interactive session activities; (b) feasibility - suitable in primary care but a therapeutic challenge to shift from group to individual format; more time in group needed (c) appropriateness - flexibility promotes relevance and fit; strategies contribute to learning and behavioral change.

This study illustrates how an intervention can be developed to fit a specific setting. A preliminary version of the stepped-care intervention yielded feedback that will be used to finalize the protocol. Larger-scale clinical trials are planned to evaluate feasibility and effectiveness.

The online version contains supplementary material available at 10.1186/s12875-026-03191-y.