'E' therapy in the community: Examination of the uptake and effectiveness of BRAVE (a self-help computer programme for anxiety in children and adolescents) in primary care

Effectiveness of internet-delivered cognitive behavioural therapy for anxiety and obsessive-compulsive disorders within routine clinical care in rural Sweden

Few studies have evaluated the implementation of ICBT in regular child and adolescent mental health services (CAMHS). This study aimed to explore the acceptability, feasibility, and effectiveness of ICBT for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD) within a rural CAMHS. The study also explored outcome predictors and long-term outcomes. Eighty-three participants were consecutively recruited from a non-specialized CAMHS in Region Jämtland Härjedalen in northern Sweden. Therapist-guided ICBT was offered during 12 weeks to children aged 8-17 with an anxiety disorder or OCD. Acceptability and feasibility measures included treatment adherence, treatment satisfaction, and adverse events. The primary outcome measure was the Clinical Global Impression-Severity. Secondary measures of effectiveness included clinician-, self-, and parent-ratings of symptom severity and functional impairment. Assessments were completed at baseline, post-treatment, and three-month follow-up (primary endpoint). A two-year follow up was conducted using medical records. Potential predictors included both patient characteristics and treatment variables. Results indicated that ICBT was both acceptable and feasible according to study measures. Statistically significant improvements were found from baseline to the three-month follow-up on clinician rated severity (B [SE] = -0.92 [0.09]; p < .001), as well as on all secondary measures. Forty-three percent of participants no longer fulfilled criteria for their principal disorder at the three-month follow-up. No serious adverse events were reported. Clinical improvement was highest among children with higher functioning at baseline (B [SE] = -0.05 [0.02]; p < .05). Forty-six percent of participants had been in contact with CAMHS during the two-year follow-up period, mainly for reasons other than their initial diagnosis. Findings suggest that ICBT could be an acceptable and feasible treatment option for young people with anxiety disorders and OCD in rural non-specialized CAMHS settings. Further studies are needed to confirm treatment effectiveness in this setting. Trial registration: NCT02926365.

The Role of Moderators in Facilitating and Encouraging Peer-to-Peer Support in an Online Mental Health Community: A Qualitative Exploratory Study

Online peer support platforms have gained popularity as a potential way for people struggling with mental health problems to share information and provide support to each other. While these platforms can offer an open space to discuss emotionally difficult issues, unsafe or unmoderated communities can allow potential harm to users by spreading triggering content, misinformation or hostile interactions. The purpose of this study was to explore the role of moderators in these online communities, and how moderators can facilitate peer-to-peer support, while minimizing harms to users and amplifying potential benefits. Moderators of the Togetherall peer support platform were recruited to participate in qualitative interviews. The moderators, referred to as 'Wall Guides', were asked about their day-to-day responsibilities, positive and negative experiences they have witnessed on the platform and the strategies they employ when encountering problems such as lack of engagement or posting of inappropriate content. The data were then analyzed qualitatively using thematic content analysis and consensus codes were deduced and reviewed to reach final results and representative themes. In total, 20 moderators participated in this study, and described their experiences and efforts to follow a consistent and shared protocol for responding to common scenarios in the online community. Many reported the deep connections formed by the online community, the helpful and thoughtful responses that members give each other and the satisfaction of seeing progress in members' recovery. They also reported occasional aggressive, sensitive or inconsiderate comments and posts on the platform. They respond by removing or revising the hurtful post or reaching out to the affected member to maintain the 'house rules'. Lastly, many discussed strategies they elicit to promote engagement from members within the community and ensure each member is supported through their use of the platform. This study sheds light on the critical role of moderators of online peer support communities, and their ability to contribute to the potential benefits of digital peer support while minimizing risks to users. The findings reported here accentuate the importance of having well-trained moderators on online peer support platforms and can guide future efforts to effectively train and supervise prospective peer support moderators. Moderators can become an active 'shaping force' and bring a cohesive culture of expressed empathy, sensitivity and care. The delivery of a healthy and safe community contrasts starkly with non-moderated online forums, which can become unhealthy and unsafe as a result.

Mindful Parenting Group Intervention for Parents of Children with Anxiety Disorders

Parenting behaviour and rearing style contribute to the intergenerational relationship between parental and child anxiety. Current psychological interventions for child anxiety typically do not adequately address parental mental health, parenting behaviours or the parent-child relationship. The current pilot study examines the effectiveness of a mindful parenting intervention (MPI) for parents of young children with clinical anxiety. It was hypothesised that the intervention would be associated with improvements in parental stress, mental health, and mindfulness, and a reduction in child clinical anxiety symptoms. Twenty-one parents of children aged 3-7 years diagnosed with anxiety disorders participated in an 8-week group MPI program that aimed to increase their intentional moment to moment awareness of the parent-child relationship. Parental (anxiety, depression, hostility, stress, burden, mindfulness, mindful parenting) and child (anxiety diagnoses, anxiety severity, comorbidities) outcomes were assessed at pre- and post-intervention, and at 3-month follow-up. Parents reported a significant increase in mindful parenting and a significant reduction in parent-child dysfunctional interaction, but no change in mental health symptoms. There was a significant reduction in parent-rated child anxiety symptoms, severity of child anxiety diagnosis and number of comorbid diagnoses at post and 3-month follow-up. Limitations include a lack of waitlist control, small sample size, and participants were largely mothers, from intact families and highly educated. There was attrition of 43% and outcomes were predominantly self-report. MPIs offer a novel and potentially effective method of increasing mindful parenting, decreasing dysfunctional parent-child interactions, reducing parenting stress and might also be an effective early intervention for indirectly decreasing young children's clinical anxiety symptoms. Larger-scale controlled trials of MPIs are needed.

Characteristics and Potential Challenges of Digital-Based Interventions for Children and Young People: Scoping Review (Preprint)

BACKGROUND

Digital health technologies are becoming increasingly available to children and young people and their families. However, there are no scoping reviews that provide both an overview of the characteristics of digital interventions for children and young people and potential challenges to be considered when developing and implementing them.

OBJECTIVE

This study aimed to systematically review scientific publications to identify the current characteristics and potential complications of digital interventions for children and young people.

METHODS

This scoping review was conducted using the framework of Arksey and O'Malley and adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. A search of 5 databases (PubMed, Scopus, Embase, MEDLINE, and CINAHL) and Google Scholar was performed for eligible clinical trials published between January 1, 2018, and August 19, 2022.

RESULTS

The initial search of the 5 databases yielded 3775 citations; duplicates and those not meeting the inclusion criteria were eliminated. In total, 34 articles were included in the final review and relevant information, such as the descriptive characteristics and potential challenges, were classified. Mental health (26/34, 76%) was the most common target for the digital intervention for children and young people, exceeding physical health (8/34, 24%) by more than 3 times. In addition, a substantial number of digital interventions were dedicated solely to children and young people. Digital interventions for children and young people were more likely to be delivered via computers (17/34, 50%) rather than smartphones (13/34, 38%). More than one-third of the studies (13/34, 38%) applied cognitive behavioral theory as the theory of digital interventions. The duration of the digital intervention for children and young people was more likely to vary depending on the target user rather than the target disease. Intervention components were classified into 5 categories: guidance, task and activity, reminder and monitoring, supportive feedback, and reward system. Potential challenges were subcategorized into ethical, interpersonal, and societal challenges. For ethical challenges, the consent of children and young people or caregivers, potential risk of adverse events, and data privacy issues were considered. For interpersonal challenges, the engagement of children and young people was affected by the preference or barrier of caregivers to participate in studies. For societal challenges, restricted ethnicity in recruitment, limited availability of digital technology, differences in internet use patterns between girls and boys, unified clinical settings, and language barriers were described.

CONCLUSIONS

We identified potential challenges and provided suggestions about ethical, interpersonal, and societal aspects to consider when developing and deploying digital-based interventions for children and young people. Our findings provide a thorough overview of the published literature and may serve as a comprehensive, informative foundation for the development and implementation of digital-based interventions for children and young people.

A Review of Studies on the Covid-19 Pandemic and the Psychological Effects of Related Measures on Children, Youth and Parents

Pandemics are social events that affect individuals' lives in many ways and have a significant impact on the mental health of masses. Pandemics and measures taken to combat these epidemics affect children and young people as well as adults. The purpose of the current review is to compile studies that have been conducted on the psychological effects of the COVID-19 pandemic and related measures on children, youth, and parents, and use the findings to shed light on future studies. In this review, 35 studies that were determined as a result of a comprehensive search in relevant literature were examined. It was observed that the aforementioned studies noted that the COVID-19 global pandemic and the measures taken to combat the epidemic (e.g., quarantine, lockdown, and school closures) had negative psychological effects on children, young people, and parents. Problems observed in children and young people, such as the fear of catching or transmitting the virus, getting bored, not being able to communicate enough with friends and teachers, and problems observed in parents, such as the troubles of negative repercussions of working at home or unemployment and difficulties in communicating with children with the closure of schools, are only a few to name these negative effects. The reviewed studies were discussed taking their limitations into account. Recommendations were made for future studies and intervention programs to be planned for community mental health. Keywords: COVID-19, children and youth, parents, pandemic, quarantine.

Protocol for a randomised placebo-controlled trial investigating the efficacy and safety of a vitamin-mineral formula targeting dysregulated emotions in teenagers: The balancing emotions of adolescents with micronutrients (BEAM) study

Background

Emotional dysregulation (ED) is a significant contributing factor to psychological distress in young people. ED is a transdiagnostic dimension characterized by an excessive reactivity to negative emotional stimuli with affective (anger) and behavioral (aggression) components, and is present across anxiety, mood and behavioral disorders. Due to early onset, high prevalence and persistence, ED in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions, with not enough children improving with conventional treatments. Clinical trials have established preliminary efficacy of micronutrients (vitamins and minerals) in the treatment of ED. This project expands the research to examine micronutrient efficacy for teenagers with ED.

Methods

This study is the first double-blind (participant and investigators) 8 week randomized controlled trial (with 8 week open-label extension and one year follow-up) designed to explore the efficacy and safety of micronutrients compared with placebo in 150 medication-free emotionally dysregulated youth (12–17 years), referred via self-referral, delivered remotely throughout New Zealand, using a website for monitoring symptoms, with a psychologist available online via text, email and video for assessment and monitoring. The primary outcome measures will be the Clinical Global Impression (CGI-I), the reactivity subscale of the Emotion Dysregulation Inventory (EDI) and the Clinician Rated Temper and Irritability Scale (CL-ARI).

Discussion

Micronutrient intervention delivered alongside online assessment and monitoring has the potential to transform delivery of mental health care to young people who may not be willing or able to access traditional therapies. We also hope that this intervention shows acceptability across different ethnicities.

Online Support and Intervention (OSI) for child anxiety: a case series within routine clinical practice

BACKGROUND

Online treatments for child anxiety offer a potentially cost-effective and non-stigmatizing means to widen access to evidence-based treatments and meet the increasing demand on services; however, uptake in routine clinical practice remains a challenge. This study conducted an initial evaluation of the clinical effectiveness, feasibility and acceptability of OSI (Online Support and Intervention for child anxiety) within clinical practice. OSI is a co-designed online therapist-supported, parent-led CBT treatment for pre-adolescent children with anxiety problems.

METHOD

This case series was part of routine service evaluation in a clinic in England where families were offered OSI to treat a primary anxiety difficulty among 7- to 12-year-old children; 24 families were offered OSI, and 23 took it up. Measures of anxiety symptomatology, functional impairment and progress towards therapeutic goals were taken at pre-treatment, post-treatment and 4-week follow-up. Treatment satisfaction and engagement were also measured throughout the intervention.

RESULTS

Mean anxiety symptoms significantly improved to below the clinical cut-off post-treatment, with further reduction at follow-up. Functional impairment also significantly improved and significant progress was made towards treatment goals. The majority of children showed reliable change in anxiety symptoms and reliable recovery by follow-up, and were discharged without needing further treatment for anxiety. Uptake, adherence and engagement in OSI were excellent, and parents reported high levels of satisfaction with the treatment.

CONCLUSIONS

We have provided initial evidence that OSI is feasible, acceptable to families, and appears to be associated with good outcomes within routine clinical practice.

Digital Interventions to Support Population Mental Health in Canada During the COVID-19 Pandemic: Rapid Review

BACKGROUND

The COVID-19 pandemic has resulted in a number of negative health related consequences, including impacts on mental health. More than 22% of Canadians reported that they had felt depressed in the last week, in response to a December 2020 national survey. Given the need to physically distance during the pandemic, and the increase in demand for mental health services, digital interventions that support mental health and wellness may be beneficial.

OBJECTIVE

The purpose of this research was to identify digital interventions that could be used to support the mental health of the Canadian general population during the COVID-19 pandemic. The objectives were to identify (1) the populations these interventions were developed for, inclusive of exploring areas of equity such as socioeconomic status, sex/gender, race/ethnicity and culture, and relevance to Indigenous peoples and communities; (2) the effect of the interventions; and (3) any barriers or facilitators to the use of the intervention.

METHODS

This study was completed using a Cochrane Rapid Review methodology. A search of Embase, PsycInfo, Medline, and Web of Science, along with Google, Million Short, and popular mobile app libraries, was conducted. Two screeners were involved in applying inclusion criteria using Covidence software. Academic articles and mobile apps identified were screened using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields resource, the American Psychiatric Association App Evaluation Framework, and the Mental Health Commission of Canada's guidance on app assessment and selection.

RESULTS

A total of 31 mobile apps and 114 web-based resources (eg, telemedicine, virtual peer support groups, discussion forums, etc) that could be used to support the mental health of the Canadian population during the pandemic were identified. These resources have been listed on a publicly available website along with search tags that may help an individual make a suitable selection. Variability exists in the populations that the interventions were developed for, and little assessment has been done with regard to areas of equity. The effect of the interventions was not reported for all those identified in this synthesis; however, for those that did report the effect, it was shown that they were effective in the context that they were used. A number of barriers and facilitators to using these interventions were identified, such as access, cost, and connectivity.

CONCLUSIONS

A number of digital interventions that could support population mental health in Canada during the global COVID-19 pandemic were identified, indicating that individuals have several options to choose from. These interventions vary in their purpose, approach, design, cost, and targeted user group. While some research and digital interventions addressed equity-related considerations, more research and focused attention should be given to this area.

Practitioner review: health anxiety in children and young people in the context of the COVID-19 pandemic

Health-related fear is a normal and common response in the face of the global pandemic of COVID-19. Children and young people are frequently being exposed to messages about the threat to health, including from the media and authorities. Whilst for most, their anxiety will be proportionate to the threat, for some, existing pre-occupation with physical symptoms and illness will become more problematic. There is a growing body of evidence that health anxiety may occur in childhood, however much of the literature is taken from research using adult samples. This practitioner review aims to give an overview of the assessment and treatment of health-related worries in children and young people in the context of the COVID-19 pandemic. This review is based on the limited existing evidence in this population and the more substantial evidence base for treating health anxiety in adults. We consider the adaptations needed to ensure such interventions are developmentally appropriate.

Child-Focused Mental Health Interventions for Disasters Recovery: A Rapid Review of Experiences to Inform Return-to-School Strategies After COVID-19

There is a worldwide need for mental health interventions to address the mental health needs of children under 12 who are returning to school in the post-COVID-19 environment. The basic characteristics of child-focused, post-crisis interventions are currently unknown, but they are essential for developing high-quality, expedient RTC programs. We conducted a rapid systematic review, via established PICO methodology, to appraise the characteristics of such interventions. We queried databases (PubMed, PsycInfo, ERIC) for English and Spanish publications describing mental health interventions to reduce mental health symptoms and sequelae among children exposed to disasters and other community crises. We described the following characteristics: type of intervention, length, number of sessions, number of staff delivering the intervention, and other characteristics. A total of 18 original articles met the inclusion criteria: 11 correspond to a controlled trial type of study and 15 addressed PTSD after disaster or crisis situations. Cognitive-behavioral therapy (CBT) was the most common intervention type, school-based/related interventions were the most common method, and five articles described an important role of teachers as mediators of therapy.

Using Peer Support to Strengthen Mental Health During the COVID-19 Pandemic: A Review

Background: The coronavirus (COVID-19) pandemic has had a significant impact on society's overall mental health. Measures such as mandated lockdowns and physical distancing have contributed to higher levels of anxiety, depression, and other metrics indicating worsening mental health. Peer support, which is peer-to-peer provided social and emotional support, is an underutilized and effective mental health resource that can potentially be used to ameliorate mental health during these times. Objective: This review aims to summarize the toll that this pandemic has had on society's mental health as found in peer-reviewed literature from October 2019 to March 2021, as well as suggest the utility of peer support to address these needs. Methods: References for this review were chosen through searches of PubMed, Web of Science, and Google Scholar for articles published between October 2019 and March 2021 that used the terms: "coronavirus," "COVID-19," "mental health," "anxiety," "depression," "isolation," "mental health resources," "peer support," "online mental health resources," and "healthcare workers." Articles resulting from these searches and relevant references cited in those articles were reviewed. Articles published in English, French and Italian were included. Results: This pandemic has ubiquitously worsened the mental health of populations across the world. Peer support has been demonstrated to yield generally positive effects on the mental health of a wide variety of recipients, and it can be provided through numerous accessible mediums. Conclusions: Peer support can overall be beneficial for improving mental health during the COVID-19 pandemic and may be an effective tool should similar events arise in the future, although the presence of a few conflicting studies suggests the need for additional research.

Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19

OBJECTIVE

Disease containment of COVID-19 has necessitated widespread social isolation. We aimed to establish what is known about how loneliness and disease containment measures impact on the mental health in children and adolescents.

METHOD

For this rapid review, we searched MEDLINE, PsycInfo, and Web of Science for articles published between January 1, 1946, and March 29, 2020. Of the articles, 20% were double screened using predefined criteria, and 20% of data was double extracted for quality assurance.

RESULTS

A total of 83 articles (80 studies) met inclusion criteria. Of these, 63 studies reported on the impact of social isolation and loneliness on the mental health of previously healthy children and adolescents (n = 51,576; mean age 15.3 years). In all, 61 studies were observational, 18 were longitudinal, and 43 were cross-sectional studies assessing self-reported loneliness in healthy children and adolescents. One of these studies was a retrospective investigation after a pandemic. Two studies evaluated interventions. Studies had a high risk of bias, although longitudinal studies were of better methodological quality. Social isolation and loneliness increased the risk of depression, and possibly anxiety at the time at which loneliness was measured and between 0.25 and 9 years later. Duration of loneliness was more strongly correlated with mental health symptoms than intensity of loneliness.

CONCLUSION

Children and adolescents are probably more likely to experience high rates of depression and most likely anxiety during and after enforced isolation ends. This may increase as enforced isolation continues. Clinical services should offer preventive support and early intervention where possible and be prepared for an increase in mental health problems.

Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia

Obsessive-compulsive disorder (OCD) can be successfully treated with cognitive behaviour therapy (CBT). However, as few patients have access to CBT, there is a strong push to develop and evaluate scalable and cost-effective internet-delivered interventions. BIP OCD is a therapist-guided online CBT intervention for pediatric OCD that has shown promise in trials conducted at a single site in Stockholm, Sweden. In this study, we evaluated if BIP OCD is an acceptable, feasible, and effective treatment in other countries and clinical contexts. Thirty-one patients were recruited at three different sites; a specialist OCD clinic in Gothenburg (Sweden), a specialist OCD clinic in London (United Kingdom), and a university-based clinic in Brisbane (Australia). Acceptability and feasibility measures included treatment adherence and feedback from therapists. Clinician assessments were conducted at baseline, post-treatment, and 3-month follow-up. The average module completion for the participants was 8.1/12 (SD = 3.2) and the majority of patients completed the BIP OCD treatment (100% in Gothenburg, and 55.6% in both London and Brisbane). Pooling data from the three sites, the within-group effect sizes from baseline to post-treatment on the Children's Yale-Brown Obsessive-Compulsive Scale were in the expected range (bootstrapped Cohen's d = 1.78; 95% CI 1.18-2.39), with an additional symptom reduction to the 3-month follow-up (bootstrapped Cohen's d = 0.27; 95% CI 0.02-0.51). Participating therapists identified both advantages and difficulties supporting patients in this digital format. The results of this study suggest that the treatment effects obtained in the original BIP OCD trials can be generalized to other clinical contexts nationally and internationally. Lessons learned provide important information for successful implementation of BIP OCD in regular healthcare contexts.

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.