Large-Scale Dissemination of Internet-Based Cognitive Behavioral Therapy for Youth Anxiety: Feasibility and Acceptability Study

Prevention of Emotional Problems in Spanish Schoolchildren: Effectiveness of the Super Skills Multimedia Program to Promote Social-Emotional Skills

Compared to traditional psychosocial interventions, the transdiagnostic approach focuses on common processes or factors that contribute to the development and maintenance of emotional problems. In Spain, the Super Skills Program has proven its effectiveness, but issues with displacement or scheduling for families can hinder access to the intervention. This study aims to examine the program's effectiveness in preventing children's psychosocial problems through learning socio-emotional skills when self-administered via the Internet. Participants were 283 Spanish children between the ages of 8 and 12. The children and their parents completed anxiety and depression scales before and after receiving the intervention and 12 months later. The program consisted of 8 self-applied sessions, at a rate of two per week, which included emotional education, cognitive restructuring, self-regulation techniques, training in social skills, problem-solving, and video feedback with cognitive preparation. Significant differences in anxiety and depression symptoms were found after the intervention. A significant reduction in anxiety scores and a marginally significant decrease in depression scores was observed at the long-term follow-up. The "intention to treat" analysis revealed a tendency for children who improved to drop out of the program, completing the intervention children with more symptomathology. Learning socio-emotional skills through a self-applied intervention via the Internet effectively reduced emotional symptoms in school children and is a valuable resource to improve child well-being and prevent future psychological problems.

Intervention for school anxiety and absenteeism in children (ISAAC): Co-designing a brief parent-focused intervention for emotionally-based school avoidance

Emotionally-based school avoidance (EBSA) is an important driver of persistent school absenteeism and may have worsened in the context of COVID-19. This paper describes the development of a brief parent-focused psychosocial intervention with the goal to address the lack of accessible early interventions for EBSA. The developmental process used a person-based approach with two phases. In Phase 1, qualitative data were collected about intervention preferences and priorities from N = 10 parents and N = 7 practitioners in a series of co-design workshops. Phase 2 refined an intervention blueprint based on iterative consultations with N = 4 parents and N = 3 practitioners. Framework analysis was used to organise findings around key intervention parameters, including relevant mechanisms, content, and delivery methods needed to provide effective, acceptable and feasible support for families affected by EBSA. The resulting blueprint incorporates three online modules to be delivered over three weeks with each module consisting of psychoeducational videos, self-completed learning tasks and a corresponding coaching session. Respective module content includes: (i) self-care strategies to increase parent wellbeing and self-efficacy; (ii) parenting strategies to change behavioural patterns that maintain child distress and avoidance of school; and (iii) strategic communication strategies to increase the quality of home-school relationships. The blueprint has been developed into a full prototype for a forthcoming feasibility study.

Frontline professionals' use of and attitudes towards technology to support interventions for adolescents with depression symptoms: A mixed methods survey

METHOD

Cross-sectional survey of a convenience sample of professionals in the UK (N = 115, including low intensity practitioners, GPs, education staff, school nurses). The survey included rating scales and free text boxes. Quantitative data were analysed descriptively, and we used reflexive thematic analysis for the qualitative data.

RESULTS

Frontline professionals rate their technological competence as good and have favourable attitudes towards using technology to support adolescents with depression symptoms. They rated online resources as most useful with mild-moderate symptoms, compared to severe symptoms (t(110) = 14.54, p < .001, Cohen's d = 1.49). Technology was viewed as important to bridge the needs-access gap and professionals were interested in learning about online SSIs due to usefulness (r = .32, p < .001).

CONCLUSION

Technology, such as SSIs, are of interest to mental health professionals and may be useful for supporting adolescents with depression. Future research should explore the use of SSIs for treating adolescent depression.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Understanding parent perspectives on engagement with online youth-focused mental health programs

OBJECTIVE

Online youth-focused health programs often include parent modules-that equip parents with skills to assist their child in improving their health-alongside youth-specific content. BRAVE Self-Help, an evidence-based program designed for children and teenagers with early signs of anxiety, is a popular Australian program that includes six parent modules. Despite its popularity and proven efficacy, BRAVE Self-Help shares the same challenge as many online self-help programs-that of low participant engagement. Using parents registered in BRAVE Self-Help as 'information rich' participants, we explored (a) factors that influenced parent engagement in online health programs, and (b) their recommendations for enhancing parent engagement.

DESIGN AND OUTCOME MEASURE

We conducted semi-structured interviews with 14 parents registered in BRAVE Self-Help. Data were analysed through reflexive thematic analysis.

RESULTS

Social-, family- and program-related factors drove parents' program engagement and recommendations. Social sub-themes related to the benefits of professional and community support in promoting more engagement. Family sub-themes included difficulties with program engagement due to competing priorities, perceptions that condition severity influenced engagement, and feelings that previously-acquired health knowledge reduced motivation to engage. Program sub-themes included perceived usefulness and ease-of-use.

CONCLUSION

Program designers could target support systems, include flexible delivery options, and use iterative design processes to enhance parent engagement.

Barriers to and facilitators of user engagement with web-based mental health interventions in young people: a systematic review

Many young people (YP) are diagnosed with mental illnesses and require support. Web-based mental health interventions (W-MHIs) have been increasingly utilized by YP, healthcare providers, and parents due to reasons including convenience and anonymity. W-MHIs are effective in improving mental health in YP. However, real-world engagement with W-MHIs remains low. Therefore, understanding barriers/facilitators of user engagement with W-MHIs is necessary to promote W-MHIs and help users gain optimal benefits through higher engagement. This review aims to identify barriers/facilitators of user engagement with W-MHIs in YP aged 10-24 years. A systematic search of five databases for English language, peer-reviewed publications was conducted between January 2010 and February 2023. Studies examining factors influencing user engagement with W-MHIs, described as barriers or facilitators, were included. Study quality was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was performed. Of 4088 articles identified, 69 studies were included. Barriers/facilitators were reported by young people (63 studies), providers (17 studies), and parents/caregivers (8 studies). YP perceived that usefulness and connectedness were the most common facilitators, whereas low-perceived need was the most reported barrier. Both providers and parents reported that perceived usefulness for YP was the most common facilitator, whereas concerns about program effectiveness and privacy were noted as barriers. This review found that program- and individual-related factors were important determinants of engagement with W-MHIs. This review provides guidance on the future design and development of new interventions, narrowing the gap between existing W-MHIs and unmet needs of users.

Study protocol for a randomized controlled trial testing the efficacy of Emotion Detectives In-Out: a blended version of the unified protocol for transdiagnostic treatment of emotional disorders in Portuguese children

BACKGROUND

Childhood emotional disorders (EDs; i.e., anxiety and depressive disorders) are currently a public health concern. Their high prevalence, long-term effects, and profound influence on the lives of children and families highlight the need to identify and treat these disorders as early and effectively as possible. This clinical trial will examine the efficacy of a blended version (i.e., combining face-to-face and online sessions into one treatment protocol) of the Unified Protocol for Children (the "Emotion Detectives In-Out" program). This program is a manualized cognitive-behavioral therapy for the transdiagnostic treatment of EDs in children aged 7 to 12 years that aims to reduce the intensity and frequency of strong and aversive emotional experiences by helping children learn how to confront those emotions and respond to them in more adaptive ways.

METHODS

This study is designed as a multicenter equivalence randomized controlled parallel-group two-arm trial comparing the Emotion Detectives In-Out program with an evidenced-based group intervention for children with anxiety disorders (the Coping Cat program). Participants will be children aged between 7 and 12 years with an anxiety disorder or with clinically significant anxiety symptoms as well as one of their parents or a legal representative. A minimum sample size of 138 children (69 per group) is needed to test whether the efficacy of the proposed intervention is equivalent to that of the well-established Coping Cat intervention.

DISCUSSION

We expect Emotion Detectives In-Out to be a feasible and efficacious alternative intervention for treating children's EDs by allowing for a greater increase in children's access to care. A blended format is expected to overcome common barriers to treatment (e.g., parents´ lack of time to attend regular sessions) and make the intervention more accessible to families.

TRIAL REGISTRATION

The clinical trial is registered at ClinicalTrials.gov (Identifier: NCT05747131, date assigned February 28, 2023).

The Report of Access and Engagement With Digital Health Interventions Among Children and Young People: Systematic Review

BACKGROUND

Digital health interventions are increasingly used to deliver health-related interventions for children and young people to change health behaviors and improve health outcomes. Digital health interventions have the potential to enhance access to and engagement with children and young people; however, they may also increase the divide between those who can access technology and are supported to engage and those who are not. This review included studies that reported on the access to or engagement with digital health interventions among children and young people.

OBJECTIVE

This review aims to identify and report on access and engagement in studies involving digital health interventions among children and young people.

METHODS

A systematic review following the Joanna Briggs Institute methods for conducting systematic reviews was conducted. An electronic literature search was conducted for all studies published between January 1, 2010, and August 2022, across sources, including MEDLINE, CINAHL, and PsycINFO. Studies were included if they examined any aspect of access or engagement in relation to interventions among children and young people. The quality of the included papers was assessed, and data were extracted. Data were considered for meta-analysis, where possible.

RESULTS

A total of 3292 references were identified using search terms. Following the exclusion of duplicates and review by inclusion criteria, 40 studies were independently appraised for their methodological quality. A total of 16 studies were excluded owing to their low assessed quality and flawed critical elements in the study design. The studies focused on a variety of health conditions; type 1 diabetes, weight management and obesity, mental health issues, and sexual health were the predominant conditions. Most studies were conducted in developed countries, with most of them being conducted in the United States. Two studies reported data related to access and considered ethnicity and social determinants. No studies used strategies to enhance or increase access. All studies included in the review reported on at least 1 aspect of engagement. Engagement with interventions was measured in relation to frequency of engagement, with no reference to the concept of effective engagement.

CONCLUSIONS

Most digital health interventions do not consider the factors that can affect access and engagement. Of those studies that measured either access or engagement or both, few sought to implement strategies to improve access or engagement to address potential disparities between groups. Although the literature to date provides some insight into access and engagement and how these are addressed in digital health interventions, there are major limitations in understanding how both can be enhanced to promote equity. Consideration of both access and engagement is vital to ensure that children and young people have the ability to participate in studies.

TRIAL REGISTRATION

PROSPERO CRD42020170874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170874.

Stepped-care versus therapist-guided, internet-based cognitive behaviour therapy for childhood and adolescent anxiety: A non-inferiority trial

Objective

This preregistered randomized trial examined whether a stepped-care approach to internet-delivered cognitive behaviour therapy (ICBT-SC) is non-inferior to therapist-guided ICBT (ICBT-TG) for child and adolescent anxiety.

Method

Participants were 137 Australians, aged 8-17 years (56 male), with a primary anxiety disorder. This randomized, non-inferiority trial compared ICBT-SC to an evidence-based, ICBT-TG program with assessments conducted at baseline, 12 weeks and 9-months after treatment commencement. All ICBT-SC participants completed the first 5 online sessions without therapist guidance. If they responded to treatment in the first 5 sessions (defined as reductions of anxiety symptoms into non-clinical range), they continued without therapist guidance for the final 5 sessions. If they did not respond to treatment in the first 5 sessions, the final five sessions were supplemented with therapist-guidance (through email). All ICBT-TG participants received therapist guidance (email) after each session, for all 10 sessions. Measures included clinical diagnostic interview (severity rating as primary outcome), as well as parent and child reported anxiety and anxiety-related interference (secondary outcomes).

Results

ICBT-SC was found to be non-inferior to ICBT-TG on primary and secondary outcomes, according to clinician, parent and young person report at 12-weeks and 9-months. Treatment satisfaction was moderate to high for both conditions. Significant clinical benefits were evident for participants in both treatments. Of participants who remained in the study, 77 % (50.7 % ITT) of ICBT-SC and 77 % (57.1 % ITT) of ICBT-TG were free of their primary anxiety diagnosis by 9-month follow-up, with no differences between conditions.

Conclusion

A stepped-care ICBT approach for clinically anxious children and adolescents may offer an acceptable treatment model that can increase access to evidence-based treatment.

Parents' acceptability of blended psychological interventions for children with emotional disorders

Objectives

This study aims to (1) describe parents' knowledge and use of online resources to address children's mental health issues and the family's general internet and technology usage patterns; (2) examine parents' acceptance of blended interventions for children with emotional disorders (ED); and (3) analyse the predictors of parents' intention to use a blended intervention if their children experienced an ED.

Method

The sample included 164 Portuguese parents (95.7 % mothers) of children between the ages of 6 and 13 years who completed an online survey. The study was disseminated through social networks, personal contacts of the researchers, and among parents participating in a randomized controlled trial investigating the efficacy of a psychological intervention for children with ED.

Results

Only 4.3 % of parents knew about online psychological interventions for children, and only 1.2 % had used them before. Most parents (73.2 %) reported that they would choose face-to-face individual therapy as their first option if their child had any ED, followed by blended therapy (14.8 %). Regression analyses showed that higher levels of parents' intention to use a blended intervention were predicted by their perceptions of the utility or efficacy of this type of delivery format.

Discussion/conclusion

These results suggest that although most parents show unfamiliarity with blended psychological interventions for children, they consider it a treatment modality to which they would resort if their children had emotional difficulties. Their intention to use such an intervention seems to be more likely if they perceive it as useful and effective.

Individually Tailored and Culturally Adapted Internet-Based Cognitive Behavioral Therapy for Arabic-Speaking Youths With Mental Health Problems in Sweden: Qualitative Feasibility Study

BACKGROUND

Most forcibly displaced refugees in Sweden originate from the Arab Republic of Syria and Iraq. Approximately half of all refugees are aged between 15 and 26 years. This particular group of youths is at a higher risk for developing various mental disorders. However, low use of mental health services across Europe has been reported. Previous research indicates that culturally adapted psychological interventions may be suitable for refugee youths. However, little is known about the feasibility, acceptability, and efficacy of such psychological interventions.

OBJECTIVE

This study aimed to explore the feasibility, acceptability, and preliminary efficacy of an individually tailored and culturally adapted internet-based cognitive behavioral therapy for Arabic-speaking refugees and immigrant youths in Sweden.

METHODS

A total of 17 participants were included to participate in an open trial study of an individually tailored and culturally adapted internet-based cognitive behavioral therapy targeting common mental health problems. To assess the intervention outcome, the Hopkins Symptom Checklist was used. To explore the acceptability of the intervention, in-depth interviews were conducted with 12 participants using thematic analysis. Feasibility was assessed by measuring treatment adherence and by calculating recruitment and retention rates.

RESULTS

The intervention had a high dropout rate and low feasibility. Quantitative analyses of the treatment efficacy were not possible because of the high dropout rate. The qualitative analysis resulted in 3 overarching categories: experiences with SahaUng (the treatment), attitudes toward psychological interventions, and personal factors important for adherence.

CONCLUSIONS

The findings from this study indicate that the feasibility and acceptability of the current intervention were low and, based on the qualitative analysis, could be increased by a refinement of recruitment strategies, further simplification of the treatment content, and modifications to the cultural adaptation.

Short Research Article: Changes in life functioning in a self-help, online program for child and adolescent anxiety

BACKGROUND

Anxiety-related functional impairment, as reflected by life interference, is a lesser explored but highly relevant treatment outcome, and it is crucial that it be included and examined in the evaluation of treatment outcomes of internet-delivered Cognitive Behavioural Therapy (iCBT).

METHODS

This single group, pre-post study examined changes in life interference and anxiety symptoms in a sample of children (n = 1198; mean age 9.66 years) and adolescents (n = 721; mean age 13.66 years) participating in the BRAVE Self-Help program in Australia.

RESULTS

Results demonstrated that both children and adolescents showed improvements in anxiety symptoms, with effect sizes ranging from ηp 2  = .194-.318. Reductions in life interference were evident for children (ηp 2  = .008-.044), particularly later in the programme, but adolescents did not show such effects. Adolescents in the low completer group (completing 3-5 sessions) showed increases in at-home interference (ηp 2  = .038).

CONCLUSIONS

Adolescents in particular may require more sessions before entrenched life interference, such as that resulting from avoidance behaviours, can be overcome.

Feasibility, Perceived Impact, and Acceptability of a Socially Assistive Robot to Support Emotion Regulation With Highly Anxious University Students: Mixed Methods Open Trial

BACKGROUND

Mental health difficulties among university students have been rising rapidly over the last decade, and the demand for university mental health services commonly far exceeds available resources. Digital interventions are seen as one potential solution to these challenges. However, as in other mental health contexts, digital programs often face low engagement and uptake, and the field lacks usable, engaging, evidence-supported mental health interventions that may be used flexibly when students need them most.

OBJECTIVE

The aim of this study is to investigate the feasibility and acceptability of a new, in situ intervention tool (Purrble) among university students experiencing anxiety. As an intervention, Purrble was designed to provide in situ support for emotion regulation (ER)-a well-known transdiagnostic construct-directly in the moments when individuals are facing emotionally challenging situations. A secondary aim is to consider the perceived impact of Purrble on youth mental health, as reported by students over a 7-week deployment.

METHODS

A mixed methods open trial was conducted with 78 under- and postgraduate students at Oxford University. Participants were recruited based on moderate to high levels of anxiety measured by Generalized Anxiety Disorder-7 at baseline (mean 16.09, SD 3.03). All participants had access to Purrble for 7 weeks during the spring term with data on their perceived anxiety, emotion dysregulation, ER self-efficacy, and engagement with the intervention collected at baseline (pre), week 4 (mid), and week 8 (postintervention). Qualitative responses were also collected at the mid- and postintervention points.

RESULTS

The findings demonstrated a sustained engagement with Purrble over the 7-week period, with the acceptability further supported by the qualitative data indicating that students accepted Purrble and that Purrble was well-integrated into their daily routines. Exploratory quantitative data analysis indicated that Purrble was associated with reductions in student anxiety (dz=0.96, 95% CI 0.62-1.29) and emotion dysregulation (dz=0.69, 95% CI 0.38-0.99), and with an increase in ER self-efficacy (dz=-0.56, 95% CI -0.86 to -0.26).

CONCLUSIONS

This is the first trial of a simple physical intervention that aims to provide ongoing ER support to university students. Both quantitative and qualitative data suggest that Purrble is an acceptable and feasible intervention among students, the engagement with which can be sustained at a stable level across a 7-week period while retaining a perceived benefit for those who use it (n=32, 61% of our sample). The consistency of use is particularly promising given that there was no clinician engagement or further support provided beyond Purrble being delivered to the students. These results show promise for an innovative intervention model, which could be complementary to the existing interventions.

Effectiveness of a transdiagnostic computerized self-applied program targeting children with emotional problems: A randomized controlled trial

BACKGROUND

Super Skills for Life (SSL) is an eight-session transdiagnostic program based on cognitive-behavioral therapy (CBT), aimed at the indicated prevention of childhood emotional problems, which has been implemented with positive short- and long-term results. The present study aimed to examine the effects of a self-applied computerized program based on SSL that maintains the same objectives and contents as the face-to-face program.

METHODS

In this randomized controlled study, 75 children (49.3 % female) aged 8-12 years (Mage = 9.45, SD = 1.31), selected for exhibiting emotional symptoms, were randomly assigned to either the intervention (n = 35) or the waiting list control (WLC) group (n = 40). Pre- and post-intervention data were collected through self-reports and the report of parents who completed parallel versions of the same measures of emotional and behavioral problems.

RESULTS

Overall, compared to the WLC group, the intervention group showed positive effects on targeted emotional symptomatology in the short term. Based on parents' reports, a significant reduction was found in outcomes such as anxiety, depression, emotional symptoms, and internalizing problems, while self-reported results were similar except for anxiety. In addition, a positive impact was found on symptoms related to other types of difficulties (e.g., externalizing problems and general difficulties measured).

LIMITATIONS

Small sample size, non-inclusion of follow-up assessment and other informants (e.g., teachers).

CONCLUSIONS

In conclusion, this research provides novel and promising data on the self-applied computerized adapted version of the SSL program, within a multi-informant approach, suggesting that it may be a useful tool for the indicated prevention of childhood emotional problems.

What consumers, general practitioners and mental health professionals want: the co-design and prototype testing of a transdiagnostic, acceptance and commitment therapy-based online intervention to reduce distress and promote wellbeing among Australian adults

BACKGROUND

Many Australians experience mental health challenges, but only a third access face-to-face psychological services, due to multiple barriers including long waitlists. Additional strategies to prevent or help people de-escalate distress at an early stage are needed. Web-based mental health interventions are becoming increasingly acceptable to consumers and referring General Practitioners (GPs), but most are designed for specific disorders/populations. This study explores consumers' and health professionals' preferences and recommendations for the design of a transdiagnostic, Acceptance and Commitment Therapy (ACT)-based, online intervention for Australian adults.

METHODS

Thirty-five people (consumers, carers, GPs, mental health professionals) participated in one or more co-design stages. Stage 1: semi-structured interviews to establish what is wanted from such websites (n = 22). Stage 2: feedback emailed on branding options (n = 20). Stage 3: feedback provided via Zoom or an online survey after testing a website prototype (n = 19). Data were analysed using Thematic Framework Analysis and descriptive statistics.

RESULTS

Stage 1 highlighted nine key design principles (plus 25 subthemes) that participants emphasised as important to ensure the website would have broad appeal and meet their needs: (1) user choice is valued highly; (2) ACT-based content is acceptable as it is focused on helping people be proactive and 'get unstuck'; (3) non-pathologising, direct, empowering, lay language is endorsed; (4) a positive look and feel is appreciated; (5) images and videos are important to break up text and maintain engagement; (6) short text messages to aid engagement are valued; (7) provision of tailored psychoeducation for highly distressed and suicidal users is endorsed; (8) personal and proactive brand name is preferred (icanactnow); (9) diverse marketing and training activities are recommended. In Stage 2, icanactnow branding preferences were elicited (simplicity, colours to represent growth and a call to action). Stage 3 resulted in the inclusion of a safety plan template and a tailored entry portal for people referred to icanactnow by health professionals. High levels of satisfaction with the prototype were reported.

CONCLUSIONS

These findings informed icanactnow and provide insights for the development of other online mental health interventions, in ways that appeal to both consumers and professionals recommending them.

Will they or won't they? Understanding New Zealand adults' attitudes towards using digital interventions

Background

Digital interventions deliver healthcare via the internet or smartphone application to support people's well-being and health. Yet uptake is relatively poor. Furthermore, several studies exploring attitudes towards digital interventions have found inconsistent attitudes. In addition to this, regional and cultural nuances may further influence attitudes to digital interventions.

Objective

This study aimed to understand New Zealand adults' attitudes towards digital interventions and their influences.

Results

A mixed-method design consisting of a cross-sectional survey and semi-structured interviews found that New Zealand adults hold varied and complex attitudes towards digital interventions. Attitudes were found to be influenced by group membership and the scenarios in which digital interventions are made available. In addition, beliefs about the benefits and concerns surrounding digital interventions, knowledge, perceived views of others, and previous experience and confidence influenced these attitudes.

Conclusions

Findings indicated that digital interventions would be acceptable if offered as part of the healthcare service rather than a standalone intervention. Key modifiable factors that could positively influence attitudes were identified and could be leveraged to increase the perceived acceptability of digital interventions.

Predictors of Adolescents' Response to a Web-Based Intervention to Improve Psychosocial Adjustment to Having an Appearance-Affecting Condition (Young Person's Face IT): Prospective Study

BACKGROUND

Adolescents with a condition affecting their appearance that results in a visible difference can be at risk of psychosocial distress and impaired adjustment. Evidence for the effectiveness of existing interventions in improving psychosocial outcomes is limited, and relevant treatment can be difficult to access. Young Person's Face IT (YPF), a self-guided web-based intervention, has demonstrated potential in reducing social anxiety in adolescents with a visible difference. However, more knowledge is needed about the variables that contribute to variations in intervention effects to identify those who may benefit most from YPF.

OBJECTIVE

This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents' use of YPF.

METHODS

We used longitudinal data collected as part of a larger, ongoing mixed methods project and randomized controlled trial (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF. Participants were 71 adolescents (mean age 13.98, SD 1.74 years; range 11-18 years; 43/71, 61% girls) with a wide range of visible differences. The adolescents completed primary (body esteem and social anxiety symptoms) and secondary (perceived stigmatization, life disengagement, and self-rated health satisfaction) outcome measures at baseline and postintervention measurement. The predictor variables were demographic (age and gender), psychosocial (frequency of teasing experiences related to aspects of the body and appearance as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables.

RESULTS

Two-thirds (47/71, 66%) of the adolescents completed all YPF sessions and spent an average of 265 (SD 125) minutes on the intervention. Backward multiple regression analyses with a 2-tailed P-value threshold of .20 revealed that several variables were retained in the final models and predicted postintervention outcome changes. Body esteem was predicted by age (P=.14) and frequency of teasing experiences (P=.09). Social anxiety symptoms were predicted by gender (P=.12), frequency of teasing experiences (P=.03), depressive and anxiety symptoms (P=.08), and time spent on YPF (P=.06). Perceived stigmatization was predicted by age (P=.09), gender (P=.09), frequency of teasing experiences (P=.19), and depressive and anxiety symptoms (P=.06). Life disengagement was predicted by gender (P=.03), depressive and anxiety symptoms (P=.001), and time spent on YPF (P=.14). Self-rated health satisfaction was predicted by age (P=.008). However, the results were limited by relatively low explained postintervention variance, ranging from 1.6% to 24.1%.

CONCLUSIONS

This study suggests that adolescent boys, adolescents who experience higher levels of psychosocial distress related to their visible difference, and adolescents who spend sufficient time on YPF may obtain better overall intervention effects.

CBT for Youth Anxiety: How Does It Fit Within Community Mental Health?

PURPOSE OF REVIEW

We review (1) the empirical literature for cognitive behavioral therapy (CBT) for youth anxiety delivered in community settings, (2) the use of online delivery methods in this process, and (3) identified barriers and facilitators to implementation of CBT for youth anxiety in community mental health clinics (CMHCs). We provide suggestions for future work.

RECENT FINDINGS

Meta-analytic reviews of effectiveness studies suggest that outcomes comparable to those of efficacy studies can be achieved in community settings, particularly when in-session exposures occur. Several online programs support delivery of these services, with an evidence base that is promising. The notable barrier to the implementation of services is the cost of implementation and sustainability. Organizational factors such as leadership, culture, and climate are consistently identified as barriers and facilitators depending on their valence and appear to be related to implementation outcomes (e.g., on provider attitudes). The current findings need to be integrated into future studies, with a focus on further identifying facilitators (e.g., champions and online programs) of implementation. There is also the need for efforts to address organizational and individual barriers and to compare ways to reduce costs.

Optimizing Internet Use during Adolescence: eHealth Solutions

Internet offers an immense opportunity as a resource for education, training, and health promotion. This narrative review summarizes the opportunities for health promotion among adolescents through use of the Internet and technology (defined as eHealth). The details of technology and use of Internet for adolescent-health related topics such as nutrition, fitness, sexual health, adventure, and violence were searched through PubMed. The review reports few digital solutions to address key challenges during adolescence like promotion of nutrition and sexual reproductive health, prevention of noncommunicable diseases, substance abuse, and mental health issues. eHealth was concluded as a potential solution for preventive and promotional health practices during adolescence. However, concerns of Internet addiction, safety, privacy, mental health disorders, and misinformation need to be addressed and monitored during adolescence.

A randomized controlled trial evaluating the effect of an internet-based cognitive-behavioral program on anxiety symptoms in a community-based sample of adolescents

Adolescents' use of online resources to self-manage anxiety is growing. The objective of the current trial was to assess the effectiveness of an online, primarily self-led cognitive behavioral therapy (CBT) program in reducing anxiety symptoms compared to an active comparator, access to anxiety resources on a static website. A total of 563 adolescents (13-19 years) with self-identified anxiety concerns were enrolled. Self-reported anxiety symptoms were assessed pre- and post-intervention (6 weeks). Adolescents were further assessed 3 months post-intervention. Other outcomes assessed at the three time-points were quality of life (QOL) and healthcare utilization. Both interventions reduced anxiety symptoms after use. Group differences in symptom change were not significant post-intervention (p = 0.16), but were at 3 months (favouring online CBT; p = 0.04) with male participants reporting more symptom change (p = 0.03). Across time-points, as anxiety symptoms decreased, QOL increased (p < 0.001). Among participants that provided healthcare utilization before and after intervention use, the greatest changes in use were among online CBT users particularly for mental health provider visits (psychiatrist, -41.0 % vs. +18.5 %; social worker, -42.5 % vs. -22.1 %), hospital-based care (emergency department visits, -80.0 % vs. +79.4 %; hospital admissions, -76.1 % vs. +42.9 %), and use of self-help or alternative treatments (-60.0 % vs. +6.6 %). Results suggest that, over time, use of online CBT by adolescents can result in improved anxiety symptoms and fewer use of other healthcare resources compared to traditional online information seeking.

Is it safe? Exploring positive and negative outcome changes following a web-based intervention for adolescents distressed by a visible difference (YP Face IT)

Despite the importance of making sure that psychological interventions are safe, research including both positive and negative effects of novel internet-delivered support is scarce. The aim of our study was to explore whether, and in what way, a new intervention for adolescents distressed by a visible difference (YP Face IT; YPF, Norwegian version) led to positive and/or negative outcome changes. Participants were 79 adolescents (62.00% girls; M_age = 13.84, SD = 1.73), with a visible difference. All had access to the YPF programme and answered questionnaires assessing social anxiety and body esteem pre- and post-intervention. Analyses included calculations of statistical as well as clinically significant and reliable changes. Results showed that fewer participants reported clinical levels of social anxiety and low body esteem after access to YPF. Results also indicated that participants who had a positive pre- to post-intervention change had lower levels of perceived self-worth pre-intervention, and spent more time on the intervention than those with a negative pre- to post change. Three participants showed a clinically significant negative and reliable change in social anxiety or body esteem from pre- to post-intervention. However, based on an examination of these participants' characteristics, preliminary findings support the safety of YPF.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Appropriate Use and Operationalization of Adherence to Digital Cognitive Behavioral Therapy for Depression and Anxiety in Youth: Systematic Review

BACKGROUND

Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment.

OBJECTIVE

This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes.

METHODS

A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs.

RESULTS

There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this.

CONCLUSIONS

Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence.

TRIAL REGISTRATION

PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram.

Assessing Patients' Attitudes towards Telepsychotherapy: The Development of the Unified Theory of Acceptance and Use of Technology -Patient Version

This study presents the development of a self-report measure of patients' attitudes towards telepsychotherapy. The measure is based on a well-researched model of attitudes towards using technology, the Unified Theory of Acceptance and Use of Technology (UTAUT) framework (Venkatesh et al., 2003). We examined the psychometric properties of the UTAUT adapted for psychotherapy patients (UTAUT-P) in a sample of 107 psychotherapy patients who received telepsychotherapy via videoconferencing during the COVID-19 pandemic. Exploratory factor analysis resulted in a 14-item UTAUT-P version, with four factors; 1) Therapy Quality Expectancy, 2) Convenience, 3) Ease of Use, and 4) Pressure from Others, and was further corroborated by the results of the confirmatory factor analysis. Our results indicated the four-factor model's adequate fit to the data and demonstrated adequate construct validity and reliability of the UTAUT-P factors. All factors, except for Ease of Use, were significantly and positively associated with intention to use telepsychotherapy technology in the future. This study complements the research on therapists' attitudes towards telepsychotherapy, based on the therapist version of the UTAUT. The developed 14-item UTAUT-P might be a helpful, brief self-report tool in clinical practice, which might give the patient a voice around the potential use of telepsychotherapy technology in their care. This initial application of the UTAUT-P patients during the COVID-19 pandemic offers a building block for future research on patients' attitudes towards telepsychotherapy, outside the context of a forced transition.

Effectiveness of psychosocial intervention for internalizing behavior problems among children of parents with alcohol dependence: Randomized controlled trial

BACKGROUND

Parental drinking has a direct bearing on children. Behavioral problems such as anxiety and depression are common problems among children whose parents drink heavily. Psychosocial interventions have shown promising results for anxiety and depression among children; however, few studies have been conducted in the context of children of parents with alcohol dependence in India.

AIM

To evaluate the efficacy of psychosocial intervention for internalizing behavioral problems among children of parents with alcohol dependence.

METHODS

A randomized controlled trial with a 2 × 4 factorial design was adopted with longitudinal measurement of outcomes for 6 mo. Two-hundred and eleven children who met the eligibility criteria (at least one parent with alcohol dependence) at government high schools in Bangalore, India, were randomized to the experimental (n = 97) or control group (n = 98). The psychosocial intervention was administered to the experimental group in eight sessions (biweekly) over 4 wk after baseline assessment. The intervention focused on identifying and modifying negative thoughts, replacing thinking errors with realistic alternatives, modification of maladaptive behavior, developing adaptive coping skills and building self-esteem. The data was collected pre-intervention and at 1, 3 and 6 mo after the intervention. Data were analyzed using SPSS 28.0 version.

RESULTS

Mean age of the children was 14.68 ± 0.58 years, 60.5% were male, 56% were studying in 9th standard, 70.75% were from nuclear families, and mean family monthly income was 9588.1 ± 3135.2 INR. Mean duration of parental alcohol dependence was 7.52 ± 2.94 years and the father was the alcohol-consuming parent. The findings showed that there were significant psychosocial intervention effects in terms of decreasing anxiety and depression scores, and increasing self-esteem level among experimental group subjects over the 6-mo interval, when compared with the control group (P < 0.001).

CONCLUSION

The present study demonstrated that the psychosocial intervention was effective in reducing anxiety and depression, and increasing self-esteem among children of parents with alcohol dependence. The study recommends the need for ongoing psychosocial intervention for these children.

Internet-Delivered Interventions for Depression and Anxiety Symptoms in Children and Young People: Systematic Review and Meta-analysis

BACKGROUND

Mental health difficulties in children and adolescents are highly prevalent; however, only a minority receive adequate mental health care. Internet-delivered interventions offer a promising opportunity to increase access to mental health treatment. Research has demonstrated their effectiveness as a treatment for depression and anxiety in adults. This work provides an up-to-date examination of the available intervention options and their effectiveness for children and young people (CYP).

OBJECTIVE

In this systematic review and meta-analysis, we aimed to determine the evidence available for the effectiveness of internet-delivered interventions for treating anxiety and depression in CYP.

METHODS

Systematic literature searches were conducted throughout November 2020 using PubMed, PsycINFO, and EBSCO academic search complete electronic databases to find outcome trials of internet-delivered interventions treating symptoms of anxiety and/or depression in CYP by being either directly delivered to the CYP or delivered via their parents. Studies were eligible for meta-analysis if they were randomized controlled trials. Risk of bias and publication biases were evaluated, and Hedges g between group effect sizes evaluating intervention effects after treatment were calculated. Meta-analyses used random-effects models as per protocol.

RESULTS

A total of 23 studies met the eligibility criteria for the systematic review, of which 16 were included in the meta-analyses, including 977 participants in internet-delivered treatment conditions and 1008 participants in control conditions across 21 comparisons. Random-effects models detected a significant small effect for anxiety symptoms (across 20 comparisons; Hedges g=-0.25, 95% CI -0.38 to -0.12; P<.001) and a small but not significant effect for depression (across 13 comparisons; Hedges g=-0.27, 95% CI -0.55 to 0.01; P=.06) in favor of internet-delivered interventions compared with control groups. Regarding secondary outcomes, there was a small effect of treatment across 9 comparisons for impaired functioning (Hedges g=0.52, 95% CI 0.24-0.80; P<.001), and 5 comparisons of quality of life showed no effect (Hedges g=-0.01, 95% CI -0.23 to 0.21; P=.94).

CONCLUSIONS

The results show that the potential of internet-delivered interventions for young people with symptoms of anxiety or depression has not been tapped into to date. This review highlights an opportunity for the development of population-specific interventions and their research to expand our current knowledge and build an empirical base for digital interventions for CYP.

TRIAL REGISTRATION

PROSPERO CRD42020220171; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220171.

Single-Session, Internet-Based Cognitive Behavioral Therapy to Improve Parenting Skills to Help Children Cope With Anxiety During the COVID-19 Pandemic: Feasibility Study

Background

The COVID-19 pandemic has had a major impact on families’ daily routines and psychosocial well-being, and technology has played a key role in providing socially distanced health care services.

Objective

The first objective of this paper was to describe the content and delivery of a single-session, internet-based cognitive behavioral therapy (iCBT) intervention, which has been developed to help parents cope with children’s anxiety and manage daily situations with their children. The second objective was to report user adherence and satisfaction among the first participants who completed the intervention.

Methods

The Let’s Cope Together intervention has been developed by our research group. It combines evidence-based CBT elements, such as psychoeducation and skills to manage anxiety, with parent training programs that strengthen how parents interact with their child and handle daily situations. A pre-post design was used to examine user satisfaction and the skills the parents learned. Participants were recruited using advertisements, media activity, day care centers, and schools and asked about background characteristics, emotional symptoms, and parenting practices before they underwent the iCBT. After they completed the 7 themes, they were asked what new parenting skills they had learned from the iCBT and how satisfied they were with the program.

Results

Of the 602 participants who filled in the baseline survey, 196 (32.6%) completed the program’s 7 themes, and 189 (31.4%) completed the postintervention survey. Most (138/189, 73.0%) of the participants who completed the postintervention survey were satisfied with the program and had learned skills that eased both their anxiety (141/189, 74.6%) and their children’s anxiety (157/189, 83.1%). The majority (157/189, 83.1%) reported that they learned how to organize their daily routines better, and just over one-half (100/189, 53.0%) reported that the program improved how they planned each day with their children.

Conclusions

The single-session iCBT helped parents to face the psychological demands of the COVID-19 pandemic. Future studies should determine how the participation rate and adherence can be optimized in digital, universal interventions. This will help to determine what kinds of programs should be developed, including their content and delivery.

Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review

BACKGROUND

A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs.

OBJECTIVE

This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach.

RESULTS

Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%.

CONCLUSIONS

There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist.

Characteristics of Mobile Health Platforms for Depression and Anxiety: Content Analysis Through a Systematic Review of the Literature and Systematic Search of Two App Stores

Background

Mobile health (mHealth) platforms show promise in the management of mental health conditions such as anxiety and depression. This has resulted in an abundance of mHealth platforms available for research or commercial use.

Objective

The objective of this review is to characterize the current state of mHealth platforms designed for anxiety or depression that are available for research, commercial use, or both.

Methods

A systematic review was conducted using a two-pronged approach: searching relevant literature with prespecified search terms to identify platforms in published research and simultaneously searching 2 major app stores—Google Play Store and Apple App Store—to identify commercially available platforms. Key characteristics of the mHealth platforms were synthesized, such as platform name, targeted condition, targeted group, purpose, technology type, intervention type, commercial availability, and regulatory information.

Results

The literature and app store searches yielded 169 and 179 mHealth platforms, respectively. Most platforms developed for research purposes were designed for depression (116/169, 68.6%), whereas the app store search reported a higher number of platforms developed for anxiety (Android: 58/179, 32.4%; iOS: 27/179, 15.1%). The most common purpose of platforms in both searches was treatment (literature search: 122/169, 72.2%; app store search: 129/179, 72.1%). With regard to the types of intervention, cognitive behavioral therapy and referral to care or counseling emerged as the most popular options offered by the platforms identified in the literature and app store searches, respectively. Most platforms from both searches did not have a specific target age group. In addition, most platforms found in app stores lacked clinical and real-world evidence, and a small number of platforms found in the published research were available commercially.

Conclusions

A considerable number of mHealth platforms designed for anxiety or depression are available for research, commercial use, or both. The characteristics of these mHealth platforms greatly vary. Future efforts should focus on assessing the quality—utility, safety, and effectiveness—of the existing platforms and providing developers, from both commercial and research sectors, a reporting guideline for their platform description and a regulatory framework to facilitate the development, validation, and deployment of effective mHealth platforms.

The development and preliminary validation of a brief scale of emotional distress in young people using combined classical test theory and item response theory approaches: The Brief Emotional Distress Scale for Youth (BEDSY)

Reliable, valid, and brief measures are important for identifying young people in community contexts who experience mental health problems. This paper reports the development and preliminary validation of the Brief Emotional Distress Scale for Youth (BEDSY), a measure based on anxiety and depression symptoms that load strongly upon the general construct of emotional distress. Participants, aged 11-17 years, included 2663 from a community population and 281 referred anxious youth. From a pool of 20 items, eight were selected for the final scale using methods from classical test theory, followed by item response theory (IRT). The final eight items met the pre-specified criteria for skewness and kurtosis, item-total correlations, IRT characteristics, and discrimination between referred vs. community samples. Exploratory structural equation modeling for a bi-factor model indicated that 81% of total variance was explained by the general emotional distress factor. The 8-item BEDSY showed strong internal consistency, good construct validity, and acceptable sensitivity and specificity in discriminating between a community sample vs anxious youth, and between youth with and without high levels of depressive symptoms. As such the scale has strong potential as a brief screen for identifying emotionally distressed young people in community contexts.

Acceptability and Feasibility of Stepped-Care for Anxious Adolescents in Community Mental Health Services: A Secondary Analysis

Initial research suggests stepped-care approaches to therapy for youth anxiety is associated with reduced therapy time with similar therapeutic outcomes to treatment-as-usual in real-world settings. Research on the acceptability and feasibility of stepped-care approaches in routine practice is very limited. In a secondary analysis of a pilot randomised controlled trial that compared stepped-care to treatment-as-usual in adolescent mental health services, we examine acceptability and feasibility from consumer and clinician perspectives. Fifteen adolescents and ten clinicians provided brief quantitative and qualitative feedback. Some benefits were noted and these related to improved access to treatment; however, major barriers were also noted. Concerns related to the lack of consumer and clinician choice and flexibility in delivery of stepped interventions, challenges engaging adolescents with internet interventions and associated guided telephone calls, and workplace issues. Systemic changes to facilitate consumer preferences, clinician flexibility and staffing are needed for stepped-care to be feasible in routine care.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

Pilot study of a well-being app to support New Zealand young people during the COVID-19 pandemic

BACKGROUND

Well-being apps represent a promising and scalable approach for improving mental health outcomes in youth, especially during a global pandemic when access to face-to-face interventions may be limited. Whitu (meaning 7 in the New Zealand Māori language Te Reo) is a newly developed well-being app with 7 modules that support young people to learn and practice evidence-based coping skills, including relaxation, mindfulness, self-compassion, and goal-setting.

OBJECTIVE

During this pilot, we explored the acceptability, usability, and preliminary efficacy of Whitu before refining the app for a randomized controlled trial (RCT).

METHODS

We recruited 20 New Zealand young people aged 16-25 years via social media to trial the first prototype of the Whitu app over 6 weeks. Within-group differences from baseline to 2- and 6-weeks post intervention in self-reported well-being, depression, anxiety, stress, self-compassion, optimism and sleep quality were evaluated using repeated-measures ANOVA. A further 21 participants aged 16-30 years were recruited to participate in 4 focus groups to give feedback on the app's usability and cultural acceptability. Feedback was analysed using directed content analysis.

RESULTS

Statistically significant improvements in anxiety (p = 0.024) and stress (p = 0.017) were observed from baseline to 2-weeks post intervention. Improvements in well-being (p = 0.021), depression (p = 0.031), anxiety (p = 0.005), and stress (p = 0.004) were also observed from baseline to 6-weeks. No statistically significant changes were seen in self-compassion, optimism, or sleep quality. Effect sizes (partial η2s) ranged from 0.25 (depression) to 0.42 (stress). Qualitative feedback comprised of five key themes, namely: factors affecting engagement, issues with functionality, preferences regarding aesthetics, effectiveness and adverse effects, and cultural acceptability.

CONCLUSIONS

Our preliminary results suggest that Whitu may be an effective app for improving multiple dimensions of young people's well-being. Modifications to the look and feel, cultural content, and onboarding have been undertaken based on the qualitative feedback, and an RCT is currently underway.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial

BACKGROUND

Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed).

OBJECTIVE

This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help).

METHODS

This study's participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session.

RESULTS

The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements.

CONCLUSIONS

These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

Building Primary-School Children's Resilience through a Web-Based Interactive Learning Environment: Quasi-Experimental Pre-Post Study

BACKGROUND

Resilience is a person's mental ability to deal with challenging situations adaptively and is a crucial stress management skill. Psychological resilience and finding ways to cope in crises is a highly relevant topic considering the COVID-19 pandemic, which enforced quarantine, social distancing measures, and school closures worldwide. Parents and children are currently living with increased stress due to COVID-19. We need to respond with immediate ways to strengthen children's resilience. Internet-based cognitive behavioral therapy interventions for children's stress management overcome accessibility issues such as the inability to visit mental health experts owing to COVID-19 movement restrictions. An interactive learning environment was created, based on the preventive program "Friends," to overcome accessibility issues associated with delivering cognitive behavioral therapy-based interventions in formal and informal education settings.

OBJECTIVE

This study aimed to examine the effectiveness of a web-based learning environment on resilience in (1) reducing anxiety symptoms and (2) increasing emotion recognition and recognition of stress management techniques among 9-10-year-old children. We also aimed to evaluate the learning environment's usability.

METHODS

A quasi-experimental pretest-posttest control group design was used. In total, 20 fourth graders in the experimental group interacted with the learning environment over 6 weekly 80-minute sessions. Further, 21 fourth graders constituted the control group. The main data sources were (1) a psychometric tool to measure children's anxiety symptoms, namely the Greek translation of the original Spence Children's Anxiety Scale, (2) 3 open-ended questions assessing emotion recognition and recognition of stress management techniques, and (3) the System Usability Scale to measure the usability of the learning environment.

RESULTS

In both groups, there was a small but nonsignificant postintervention reduction in reported anxiety symptoms, except for obsessive-compulsive disorder symptoms in the experimental group. A paired samples t test revealed that students' reported symptom scores of obsessive-compulsive disorder significantly decreased from 1.06 (SD 0.68) to 0.76 (SD 0.61) (t₁₉= 5.16; P=.01). The experimental group revealed a significant increase in emotion recognition (t₁₉=-6.99; P<.001), identification of somatic symptoms of stress (t₁₉=-7.31; P<.001), and identification of stress management techniques (t₁₉=-6.85; P<.001). The learning environment received a satisfactory usability score. The raw average system usability score was 76.75 (SD 8.28), which is in the 80th percentile rank and corresponds to grade B.

CONCLUSIONS

This study shows that interactive learning environments might deliver resilience interventions in an accessible and cost-effective manner in formal education, potentially even in distance-learning conditions owing to the COVID-19 pandemic. Interactive learning environments on resilience are also valuable tools for parents who can use them with their children at home, for informal learning, using mobile devices. As such, they could be a promising first-step, low-intensity intervention that children and the youth can easily access.

The Youth Online Diagnostic Assessment (YODA): Validity of a New Tool to Assess Anxiety Disorders in Youth

This study developed an online diagnostic tool for anxiety disorders in youth, and evaluated its reliability and validity amongst 297 children aged 6-16 years (M_age = 9.34, 46% male). Parents completed the online tool, the Youth Online Diagnostic Assessment (YODA), which is scored either using a fully-automated algorithm, or combined with clinician review. In addition, parents and children completed a clinician-administered diagnostic interview and self-report measures of internalizing and externalizing symptoms and wellbeing. The fully-automated YODA demonstrated relatively weak agreement with the diagnostic interview for identifying the presence of any anxiety disorder and specific anxiety disorders, apart from separation anxiety (which had moderate agreement). The clinician-reviewed YODA showed better agreement than fully-automated scoring, particularly for identifying the presence of any anxiety disorder. The YODA demonstrated good agreement with parent-reported measures of symptoms/interference. The YODA offers a fully or largely automated method to determine the presence of anxiety disorders in youth, with particular value in situations where low-resource assessments are needed. While it currently requires further research and improvement, the YODA provides a promising start to the development of such a tool.

Characteristics of effective online interventions: implications for adolescents with personality disorder during a global pandemic

In recent years, the necessity of providing online interventions for adolescents, as an alternative to face-to-face interventions, has become apparent due to several barriers some adolescents face in accessing treatment. This need has become more critical with the coronavirus disease 2019 (COVID-19) global pandemic impacting the delivery of psychotherapy and limiting accessibility of face-to-face therapy. Whilst it has been established that face-to-face psychotherapy for adolescents with personality disorder can be effective in reducing the impact these complex mental illnesses have on functioning, online interventions for adolescents are rare, and to our knowledge there are no empirically validated online interventions for personality disorder. The development of novel online interventions are therefore necessary. To inform the development of online interventions for adolescents with personality disorder or symptoms of emerging personality disorder, a two-phase rapid review was conducted. Phase one consisted of a search and examination of existing online mental health programs for adolescents with symptoms of personality disorder, to understand how to best use online platforms. Phase two consisted of a rapid review of empirical literature examining online interventions for adolescents experiencing symptoms of personality disorder to identify characteristics that promote efficacy. There were no online programs specific to personality disorder in adolescence. However, 32 online mental health programs and 41 published empirical studies were included for analysis. Common intervention characteristics included timeframes of one to two months, regular confidential therapist contact, simple interactive online components and modules, and the inclusion of homework or workbook activities to practice new skills. There is an urgent need for online interventions targeting personality dysfunction in adolescence. Several characteristics of effective online interventions for adolescents were identified. These characteristics can help inform the development and implementation of novel online treatments to prevent and reduce the burden and impact of personality disorder, or symptoms of emerging personality disorder, in adolescents. This has implications for the COVID-19 pandemic when access to effective online interventions has become more urgent.

Preventive digital mental health interventions for children and young people: a review of the design and reporting of research

Digital health interventions (DHIs) have frequently been highlighted as one way to respond to increasing levels of mental health problems in children and young people. Whilst many are developed to address existing mental health problems, there is also potential for DHIs to address prevention and early intervention. However, there are currently limitations in the design and reporting of the development, evaluation and implementation of preventive DHIs that can limit their adoption into real-world practice. This scoping review aimed to examine existing evidence-based DHI interventions and review how well the research literature described factors that researchers need to include in their study designs and reports to support real-world implementation. A search was conducted for relevant publications published from 2013 onwards. Twenty-one different interventions were identified from 30 publications, which took a universal (n = 12), selective (n = 3) and indicative (n = 15) approach to preventing poor mental health. Most interventions targeted adolescents, with only two studies including children aged ≤10 years. There was limited reporting of user co-design involvement in intervention development. Barriers and facilitators to implementation varied across the delivery settings, and only a minority reported financial costs involved in delivering the intervention. This review found that while there are continued attempts to design and evaluate DHIs for children and young people, there are several points of concern. More research is needed with younger children and those from poorer and underserved backgrounds. Co-design processes with children and young people should be recognised and reported as a necessary component within DHI research as they are an important factor in the design and development of interventions, and underpin successful adoption and implementation. Reporting the type and level of human support provided as part of the intervention is also important in enabling the sustained use and implementation of DHIs.

"Don't … Break Down on Tuesday Because the Mental Health Services are Only in Town on Thursday": A Qualitative Study of Service Provision Related Barriers to, and Facilitators of Farmers' Mental Health Help-Seeking

The suicide rate of farmers is approximately double that of the general Australian population, yet farmers employ fewer help-seeking behaviours (Arnautovska et al. in Soc Psychiatry Psychiatr Epidemiol 49:593-599, 2014; Brew et al. in BMC Public Health 16:1-11, 2016). Therefore, it is crucial to understand if, and how health services and system might influence farmer help-seeking. To shed light on this, the current study employed qualitative semi-structured interviews with 10 farmers, 10 farmers' partners and 8 medical practitioners. Thematic analysis, guided by Braun and Clarke's (Qual Res Psychol 3:77-101, 2006) techniques, was used to analyse the data. Three themes were devised concerning the interaction between farmers and health services, including 'health service interactions', 'services are provided within a complex system' and 'emerging technologies: the users, practitioners, and systems'. The findings underscore the importance of interactions between a farmer and a service provider, with farmers wanting their provider to have an understanding of farming life. Help-seeking was also shaped by access, availability, and practitioner constancy. Lastly, a complex relationship between digital mental health services and farmer help-seeking was reported, with factors related to the farmers, the practitioners and the infrastructure/systems discussed. The outcomes have implications for health service and policy reform, developing and providing interventions for farmers to promote health services interaction as a way of mental health help-seeking.

Parental consent: A potential barrier for underage teens' participation in an mHealth mental health intervention

PURPOSE

We sought to examine whether underage adolescents displaying symptoms for a mental illness (i.e., an eating disorder) would be willing to obtain parental consent to participate in a study to test the efficacy of an evidence-based mobile mental health intervention targeting teens with eating disorders.

METHODS

The participants (n = 366) were 15 to 17 year-old English-speakers who post or follow social media accounts on Instagram that emphasize being thin as important or attractive. The participants were administered a survey through Qualtrics to assess eating disorder pathology, interest in trying an evidence-based mobile mental-health intervention, and comfort level with obtaining parental consent to partake in a research study about such an intervention.

RESULTS

About 85% of participants met clinical or subclinical criteria for an eating disorder; however, only 12% had received a treatment within the past six months. While 83% of participants were interested in trying a mobile health interventions app, only 35% indicated willingness to obtain parental consent to participate in a research study. The primary reasons presented for unwillingness to obtain consent included importance of retaining privacy and feeling that parents lack awareness or understanding about mental health issues.

CONCLUSIONS

While barriers exist to obtaining treatment for eating disorders, a mobile intervention app may close some of these gaps. Many underage participants indicated interest in obtaining such treatment, yet only a third were willing to obtain parental consent. Future studies should investigate how to reduce these barriers to obtaining parental consent to facilitate teen access to research and mobile mental health treatment.

Internet-delivered cognitive behavior therapy with minimal therapist support for anxious children and adolescents: predictors of response

BACKGROUND

In general, Internet-delivered cognitive behavior therapy (iCBT) produces significant reductions in child and adolescent anxiety, but a proportion of participants continue to show clinical levels of anxiety after treatment. It is important to identify demographic, clinical, and family factors that predict who is most likely to benefit from iCBT in order to better tailor treatment to individual needs.

METHODS

Participants were 175 young people (7-18 years) with an anxiety disorder, and at least one of their parents, who completed an iCBT intervention with minimal therapist support. Multilevel modeling (MLM) examined predictors of response to iCBT as measured by the slope for changes in the primary outcome measures of child- and parent-reported anxiety scores, from pretreatment, to 12-weeks, 6-month, and 12-month follow-ups, controlling for pretreatment total clinician severity ratings of all anxiety diagnoses.

RESULTS

Child age, gender, father age, parental education, parental mental health, parenting style, and family adaptability and cohesion did not significantly predict changes in anxiety in the multivariate analyses. For child-reported anxiety, greater reductions were predicted by a separation anxiety disorder diagnosis (SEP) and elevated depression, with lower reductions predicted by poor couple relationship quality. For parent-reported child anxiety, greater reductions were predicted by higher pretreatment total CSRs, SEP, and lower family income, with lower reductions for children of older mothers. Irrespective of these predictors of change, children in general showed reductions in anxiety to within the normal range.

CONCLUSIONS

Overall, children responded well to iCBT irrespective of the demographic, clinical, and family factors examined here. Poor couple relationship quality and older mother age were risk factors for less positive response to iCBT in terms of reductions in anxiety symptoms although still to within the normal range.

An Internet-Based Cognitive Behavioral Program for Adolescents With Anxiety: Pilot Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (ICBT) is a treatment approach recently developed and studied to provide frontline treatment to adolescents with anxiety disorders.

OBJECTIVE

This study aimed to pilot procedures and obtain data on methodological processes and intervention satisfaction to determine the feasibility of a definitive randomized controlled trial (RCT) to test the effectiveness of a self-managed ICBT program, Breathe (Being Real, Easing Anxiety: Tools Helping Electronically), for adolescents with anxiety concerns.

METHODS

This study employed a two-arm, multisite, pilot RCT. Adolescents aged 13 to 17 years with a self-identified anxiety concern were recruited online from health care settings and school-based mental health care services across Canada between April 2014 and May 2016. We compared 8 weeks of ICBT with ad hoc telephone and email support (Breathe experimental group) to access to a static webpage listing anxiety resources (control group). The primary outcome was the change in self-reported anxiety from baseline to 8 weeks (posttreatment), which was used to determine the sample size for a definitive RCT. Secondary outcomes were recruitment and retention rates, a minimal clinically important difference (MCID) for the primary outcome, intervention acceptability and satisfaction, use of cointerventions, and health care resource use, including a cost-consequence analysis.

RESULTS

Of the 588 adolescents screened, 94 were eligible and enrolled in the study (49 adolescents were allocated to Breathe and 45 were allocated to the control group). Analysis was based on 74% (70/94) of adolescents who completed baseline measures and progressed through the study. Enrolled adolescents were, on average, 15.3 years old (SD 1.2) and female (63/70, 90%). Retention rates at 8 weeks were 28% (13/46; Breathe group) and 58% (24/43; control group). Overall, 39% (14/36) of adolescents provided feedback on completion of the Breathe program. Adolescents' scores on a satisfaction survey indicated a moderate level of satisfaction. All but one adolescent indicated that Breathe was easy to use and they understood all the material presented. The most frequent barrier identified for program completion was difficulty in completing exposure activities. The power analysis indicated that 177 adolescents per group would be needed to detect a medium effect size (d=0.3) between groups in a definitive trial. Data for calculating an MCID or conducting a cost-consequence analysis were insufficient due to a low response rate at 8 weeks.

CONCLUSIONS

Adolescents were moderately satisfied with Breathe. However, program adjustments will be needed to address attrition and reduce perceived barriers to completing key aspects of the program. A definitive RCT to evaluate the effectiveness of the program is feasible if protocol adjustments are made to improve recruitment and retention to ensure timely study completion and increase the completeness of the data at each outcome measurement time point.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02059226; http://clinicaltrials.gov/ct2/show/NCT02059226.

Digital Approaches to Remote Pediatric Health Care Delivery During the COVID-19 Pandemic: Existing Evidence and a Call for Further Research

The global spread of the coronavirus disease (COVID-19) outbreak poses a public health threat and has affected people worldwide in various unprecedented ways, both personally and professionally. There is no question that the current global COVID-19 crisis, now more than ever, is underscoring the importance of leveraging digital approaches to optimize pediatric health care delivery in the era of this pandemic. In this perspective piece, we highlight some of the available digital approaches that have been and can continue to be used to streamline remote pediatric patient care in the era of the COVID-19 pandemic, including but not limited to telemedicine. JMIR Pediatrics and Parenting is currently publishing a COVID-19 special theme issue in which investigators can share their interim and final research data related to digital approaches to remote pediatric health care delivery in different settings. The COVID-19 pandemic has rapidly transformed health care systems worldwide, with significant variations and innovations in adaptation. There has been rapid expansion of the leveraging and optimization of digital approaches to health care delivery, particularly integrated telemedicine and virtual health. Digital approaches have played and will play major roles as invaluable and reliable resources to overcome restrictions and challenges imposed during the COVID-19 pandemic and to increase access to effective, accessible, and consumer-friendly care for more patients and families. However, a number of challenges remain to be addressed, and further research is needed. Optimizing digital approaches to health care delivery and integrating them into the public health response will be an ongoing process during the current COVID-19 outbreak and during other possible future pandemics. Regulatory changes are essential to support the safe and wide adoption of these approaches. Involving all relevant stakeholders in addressing current and future challenges as well as logistical, technological, and financial barriers will be key for success. Future studies should consider evaluating the following research areas related to telemedicine and other digital approaches: cost-effectiveness and return on investment; impact on quality of care; balance in use and number of visits needed for the management of both acute illness and chronic health conditions; system readiness for further adoption in other settings, such as inpatient services, subspecialist consultations, and rural areas; ongoing user-centered evaluations, with feedback from patients, families, and health care providers; strategies to optimize health equity and address disparities in access to care related to race and ethnicity, socioeconomic status, immigration status, and rural communities; privacy and security concerns for protected health information with Health Insurance Portability and Accountability Act (HIPAA)-secured programs; confidentiality issues for some specific populations, especially adolescents and those in need of mental health services; early detection of exposure to violence and child neglect; and integration of training into undergraduate and graduate medical education and subspecialty fellowships. Addressing these research areas is essential to understanding the benefits, sustainability, safety, and optimization strategies of telemedicine and other digital approaches as key parts of modern health care delivery. These efforts will inform long-term adoption of these approaches with expanded dissemination and implementation efforts.

Engagement in technology-enhanced interventions for children and adolescents: Current status and recommendations for moving forward

Treatment engagement is a primary challenge to the effectiveness of evidence-based treatments for children and adolescents. One solution to this challenge is technology, which has been proposed as an enhancement to or replacement for standard clinic-based, therapist delivered services. This review summarizes the current state of the field regarding technology's promise to enhance engagement. A review of this literature suggests that although the focus of much theoretical consideration, as well as funding priorities, relatively little empirical research has been published on the role of technology as a vehicle to enhance engagement in particular. Moreover, lack of consistency in constructs, design, and measures make it difficult to draw useful comparisons across studies and, in turn, to determine if and what progress has been made toward more definitive conclusions. At this point in the literature, we can say only that we do not yet definitively know if technology does (or does not) enhance engagement in evidence-based treatments for children and adolescents. Recommendations are provided with the hope of more definitively assessing technology's capacity to improve engagement, including more studies explicitly designed to assess this research question, as well as greater consistency across studies in the measurement of and designs used to test engagement.

Examining the Usage, User Experience, and Perceived Impact of an Internet-Based Cognitive Behavioral Therapy Program for Adolescents With Anxiety: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents' experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact.

OBJECTIVE

Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically (Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments (Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents.

METHODS

Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children-2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS.

RESULTS

Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents (P<.001). Breathe respondents reported program design and delivery factors that may have challenged (eg, time constraints and program support) or facilitated (eg, demonstration videos, self-management activities) program use. The MCID was a mean MASC-2 change score of 13.8 (SD 18.1). Using the MCID, a positive treatment response was generated for 43% (35/81) of Breathe respondents. Treatment response was not correlated with respondents' experiences or use of Breathe (P=.32 to P=.88).

CONCLUSIONS

Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02970734 https://clinicaltrials.gov/ct2/show/NCT02970734.

Social support as a predictor of treatment adherence and response in an open-access, self-help, internet-delivered cognitive behavior therapy program for child and adolescent anxiety

BACKGROUND

Although self-help, internet-based cognitive behaviour therapy (ICBT) can produce significant reductions in anxiety for many young people, a sizable proportion show low program adherence and continue to show anxiety problems after treatment. It is important that we identify factors that predict those most likely to complete program sessions and benefit from self-help ICBT so that we can better match interventions to individual needs, and inform program design and development.

OBJECTIVE

This study examined the role of social support in predicting treatment adherence and outcome among youth enrolled in an open-access, internet-delivered, CBT intervention targeting anxiety.

METHODS

Participants were 3684 young people (aged 7 to 17 years) who reported elevated levels of anxiety symptoms when registering for the program. Treatment adherence was assessed as number of treatment sessions completed. Treatment response was evaluated as change in self-reported anxiety symptoms. Youth-reported social support (from friends, family and a special person) at pre-treatment was examined as a hypothesized predictor of adherence and outcome after controlling for baseline anxiety, gender, and age, with age being examined as a moderator.

RESULTS

Linear regression analyses showed that participants with greater social support, from all sources, tended to show greater program adherence, although the proportion of explained variance was small. Age moderated the effect of family support upon adherence, such that greater family support was associated with greater number of sessions completed only for older youth. Greater family and total support were associated with greater reductions in anxiety, irrespective of participant age, but again the percent of variance explained was small. Younger participants were more likely to complete more sessions and to show greater reductions in anxiety. Those with higher pre-treatment anxiety tended to complete fewer sessions but demonstrated greater reductions in anxiety.

CONCLUSIONS

The findings highlight the need to consider ways to enhance treatment adherence and outcome of those engaging in self-help ICBT for youth anxiety problems, particularly when social support is low.

Potential Reduction of Symptoms With the Use of Persuasive Systems Design Features in Internet-Based Cognitive Behavioral Therapy Programs for Children and Adolescents With Anxiety: A Realist Synthesis

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) for children and adolescents is a persuasive system that combines 3 major components to therapy-therapeutic content, technological features, and interactions between the user and program-intended to reduce users' anxiety symptoms. Several reviews report the effectiveness of iCBT; however, iCBT design and delivery components differ widely across programs, which raise important questions about how iCBT effects are produced and can be optimized.

OBJECTIVE

The objective of this study was to review and synthesize the iCBT literature using a realist approach with a persuasive systems perspective to (1) document the design and delivery components of iCBT and (2) generate hypotheses as to how these components may explain changes in anxiety symptoms after completing iCBT.

METHODS

A multi-strategy search identified published and gray literature on iCBT for child and adolescent anxiety up until June 2019. Documents that met our prespecified inclusion criteria were appraised for relevance and methodological rigor. Data extraction was guided by the persuasive systems design (PSD) model. The model describes 28 technological design features, organized into 4 categories that help users meet their health goals: primary task support, dialogue support, system credibility support, and social support. We generated initial hypotheses for how PSD (mechanisms) and program delivery (context of use) features were linked to symptom changes (outcomes) across iCBT programs using realist and meta-ethnographic techniques. These hypothesized context-mechanism-outcome configurations were refined during analysis using evidence from the literature to improve their explanatory value.

RESULTS

A total of 63 documents detailing 15 iCBT programs were included. A total of six iCBT programs were rated high for relevance, and most studies were of moderate-to-high methodological rigor. A total of 11 context-mechanism-outcome configurations (final hypotheses) were generated. Configurations primarily comprised PSD features from the primary task and dialogue support categories. Several key PSD features (eg, self-monitoring, simulation, social role, similarity, social learning, and rehearsal) were consistently reported in programs shown to reduce anxiety; many features were employed simultaneously, suggesting synergy when grouped. We also hypothesized the function of PSD features in generating iCBT impacts. Adjunct support was identified as an important aspect of context that may have complemented certain PSD features in reducing users' anxiety.

CONCLUSIONS

This synthesis generated context-mechanism-outcome configurations (hypotheses) about the potential function, combination, and impact of iCBT program components thought to support desired program effects. We suggest that, when delivered with adjunct support, PSD features may contribute to reduced anxiety for child and adolescent users. Formal testing of the 11 configurations is required to confirm their impact on anxiety-based outcomes. From this we encourage a systematic and deliberate approach to iCBT design and evaluation to increase the pool of evidence-based interventions available to prevent and treat children and adolescents with anxiety.

Using stepped-care approaches within internet-based interventions for youth anxiety: Three case studies

BACKGROUND

There are a lack of clear guidelines for the dissemination of Internet-based cognitive behaviour therapy (ICBT) for childhood and adolescent anxiety in routine care. While self-guided ICBT has greater reach than therapist-guided ICBT, it is plagued by problems of low program adherence and many young people are not successfully treated. It is important that we identify models of ICBT that are accessible, but provide the right support, at the right time to those who need it. Stepped-care models of ICBT offer one potential solution.

OBJECTIVE

This case study examined the application of stepped-care within an ICBT intervention for childhood and adolescent anxiety, in which young people were stepped up from self-guided to therapist-guided ICBT.

METHODS

Three case studies are presented and include young males (aged 11-12 years) who participated in BRAVE Stepped-Care, a new ICBT program incorporating two treatment steps: Step 1 - five sessions of self-guided ICBT and Step 2 - five sessions of therapist-guided ICBT. Participants completed diagnostic assessments at pre- and post-treatment, along with a battery of self-report questionnaires. Step-up requirements were determined at a mid-treatment assessment. Treatment response was determined by change on diagnostic severity and presence of diagnosis and changes in self-reported anxiety symptoms (through T-scores and Reliable Change Indices).

RESULTS

In-depth examination of the three case studies showed that decisions to step-up from Step 1 to Step 2 were complex and required consideration of program engagement and adherence, as well as changes on self-reported anxiety, behavioural indicators of anxiety and parent perspectives. Results showed that non-responders at mid-treatment who were stepped-up to therapist-guided ICBT after Step 1 were able to increase engagement and response to treatment in Step 2, such that they were free of their primary anxiety diagnosis at post-treatment.

CONCLUSIONS

The findings highlight the importance of early assessment of engagement and non-response within self-guided ICBT programs for youth anxiety and the positive changes that can subsequently occur when therapist-guidance is introduced mid-treatment for non-responders. The efficacy of stepped-care ICBT models needs to be confirmed in larger randomised controlled trials.