The Effectiveness of Web-Based Interventions Delivered to Children and Young People With Neurodevelopmental Disorders: Systematic Review and Meta-Analysis

'If I Don't Have My Support Worker in the Room…': A Multi-perspective Mixed Methods Study of Remote Daily Living Support for Neurodivergent Young Adults

PURPOSE

Information technology is increasingly being employed for providing support and interventions in disability and health service contexts. This study aimed to investigate service users' and support workers' perspectives on remote support in daily living for young adults with neurodevelopmental conditions.

METHODS

Using a convergent mixed methods approach, we integrated qualitative and quantitative findings from survey responses and focus groups. Young service users (aged 18 to 29) diagnosed with ADHD and/or autism (n = 35) and support workers (n = 64) from four municipalities in Sweden responded to a survey designed to tap into their lived experiences and views. The topic was explored further in focus groups with young service users (n = 7) and support workers (n = 3). Open-ended survey questions were analyzed using qualitative content analyses and complemented with information from the focus groups, while closed survey questions were summarized descriptively. Inferences were merged in a joint display.

RESULTS

While participants reported having access to digital devices, service routines for remote contact were not in place. Service users were more hesitant than support workers in endorsing remote support, expressing concerns that this approach would be inferior to in-person support (e.g., owing to miscommunications and insufficient social and emotional contact). Still, both groups expressed that remote contact may at times be a beneficial complement to in-person meetings, increasing accessibility and user choice.

CONCLUSION

Service providers planning to implement remote support elements should explore the demand, acceptability, and organizational readiness for this approach. Moving forward, user engagement will be crucial to meet individual preferences, values, and needs.

Co-designing behavioural activation for depression for autistic adolescents: A case series

Autistic youth are at high risk of depression, but there are few psychological interventions that have been specifically designed for use with this population. Behavioural activation (BA) is a particularly promising approach for autistic adolescents, having an established evidence-base for the treatment of depression in non-autistic people, and with a strong focus on behavioural, rather than cognitive change, which is a challenge for some autistic people. In this study, we worked with autistic adolescents and clinicians to co-design a BA-informed intervention to be delivered in an online format. We then conducted a pilot case-series with seven autistic adolescents with depression. Our focus was on establishing the acceptability and feasibility of the intervention but clinical outcomes on both self- and parent-reported symptoms of depression and anxiety are also presented. Our results indicate the intervention to be acceptable and feasible for autistic adolescents, with six out of seven participants being retained to the end of the intervention. Qualitative feedback indicated that all participants found the intervention a positive experience and would recommend it to others. Similarly, all participants found the online format acceptable, with 64% preferring this format to face-to-face therapy. Qualitative feedback and suggestions for refinement will also be discussed.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

A randomized controlled trial of a home-based computerized executive function intervention for children with cerebral palsy

Children with cerebral palsy (CP) often show executive function (EF) impairments that are key to quality of life. The aim of this study was to assess whether a home-based computerized intervention program improves executive functions (EFs) compared to usual care. Sixty participants (30 females) with CP (8-12 years old) were paired by age, sex, motor ability, and intelligence quotient score and then randomized to intervention and waitlist control groups. The intervention group received a 12-week home-based computerized EF intervention (5 days/week, 30 min/day, total dose 30 h). Core and higher-order EFs were assessed before, immediately after, and 9 months after completing the intervention. The intervention group performed better than the waitlist control group in the three core EFs (immediately and 9 months after the intervention): inhibitory control (F = 7.58, p = 0.13 and F = 7.85, p = 0.12), working memory (F = 8.34, p = 0.14 and F = 7.55, p = 0.13), and cognitive flexibility (F = 4.87, p = 0.09 and F = 4.19, p = 0.08). No differences were found between the groups in higher-order EFs or EF manifestations in daily life.

CONCLUSIONS

A home-based computerized EF intervention improved core EFs in children with CP, but further research is needed to identify strategies that allow the transfer of these improvements to everyday life.

TRIAL REGISTRATION

NCT04025749 retrospectively registered on 19 July 2019.

WHAT IS KNOWN

• One in two children with cerebral palsy has an intellectual impairment. Visual perception and executive functions are the most reported specific cognitive deficits. • The majority of interventions for cerebral palsy focus on motor impairments, but only a few randomized controlled trials have explored the effect of interventions on executive functions.

WHAT IS NEW

• A home-based computerized cognitive intervention can improve the core executive functions of children with cerebral palsy. • Short- and long-term effects on core executive functions have been found.

Social cognition interventions for adolescents with autism spectrum disorder. A systematic review

Early intervention during childhood in patients with Autism Spectrum Disorder (ASD) has been strongly advocated. As adolescence is reached, new, more complex social demands emerge. These demands require a therapeutic approach that has not been widely studied. The aim of this review is to examine and synthesize the existing literature on social cognition interventions in adolescence and lay the groundwork for future interventions.

e-Health Interventions Targeting Pain-Related Psychological Variables in Fibromyalgia: A Systematic Review

There is growing evidence to support the potential benefit of e-Health interventions targeting psychosocial outcomes and/or pain-related psychological variables for chronic pain conditions, including fibromyalgia syndrome (FMS). This systematic review aims at providing an in-depth description of the available e-Health psychological and/or multicomponent interventions for patients with FMS. Searches were made in PubMed, Cochrane, Web of Science, and PsycINFO up to 15 May 2023, finally including twenty-six articles. The quality of the included articles was medium-high (average quality assessment score of 77.1%). 50% of studies were randomized controlled trials (RCTs) (n = 13), and the majority of them focused exclusively on adult patients with FMS (n = 23) who were predominantly female. Four categories of e-Health modalities were identified: web-based (n = 19), mobile application (m-Health) (n = 3), virtual reality (VR) (n = 2), and video consulting (n = 2). Interventions were mainly based on the cognitive behavioral therapy (CBT) approach (n = 14) and mostly involved contact with a healthcare professional through different digital tools. Overall, a growing number of psychological and multicomponent interventions have been created and delivered using digital tools in the context of FMS, showing their potentiality for improving psychosocial outcomes and pain-related psychological variables. However, some digital tools resulted as underrepresented, and the literature on this topic appears highly heterogeneous precluding robust conclusions.

Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with Developmental Language Disorder

BACKGROUND

It is well-documented that children with Developmental Language Disorder (DLD) have a higher likelihood of experiencing anxiety, as well as other socio-emotional and behavioural (SEB) difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand the prevalence of broader SEB difficulties and anxiety, informing intervention development by understanding the relationships between them.

METHODS

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD ("DLD sample"; n = 57) or typically developing children ("typical sample"; n = 50), aged 6-12 years old. Binary SEB statements informed by previous qualitative work (e.g. "my child requires routine/sameness"; "my child has frequent tantrums") provided an insight into the prevalence of SEB difficulties in both DLD and typical samples. Validated measures of anxiety, emotion regulation, intolerance of uncertainty, insistence on sameness, family stress and coping mechanisms were also collected. Correlation and mediation analyses were run using these validated measures to understand the manifestation of anxiety in children with DLD in more detail. Qualitative interviews were then carried out with a select panel of survey respondents (n = 4).

RESULTS

The DLD sample scored significantly higher on all binary SEB statements than the typical sample: experiencing anxiety (80.7%, p < .05), requiring routine and sameness (75.4%, p < .001) and emotional dysregulation (75.4%; p < .001) were the most common difficulties reported for children with DLD. Using the validated scales, family stress and coping mechanisms were found to only correlate with the manifestation of anxiety in the typical group, not the DLD group. "Intolerance of uncertainty" and "insistence on sameness" were found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Parent's interviews provided contextual support for the analysis, as well as highlighting sensory sensitivities as a focus for future research.

CONCLUSIONS

Parents of children with DLD appear to cope well with their children's complex SEB needs. Intervention focussing on intolerance of uncertainty may help the management of difficulties with anxiety. Behaviours such as insistence on sameness should be investigated further, as potential indicators for anxiety amongst children with DLD.

A meta-analysis of genetic effects associated with neurodevelopmental disorders and co-occurring conditions

A systematic understanding of the aetiology of neurodevelopmental disorders (NDDs) and their co-occurrence with other conditions during childhood and adolescence remains incomplete. In the current meta-analysis, we synthesized the literature on (1) the contribution of genetic and environmental factors to NDDs, (2) the genetic and environmental overlap between different NDDs, and (3) the co-occurrence between NDDs and disruptive, impulse control and conduct disorders (DICCs). Searches were conducted across three platforms: Web of Science, Ovid Medline and Ovid Embase. Studies were included only if 75% or more of the sample consisted of children and/or adolescents and the studies had measured the aetiology of NDDs and DICCs using single-generation family designs or genomic methods. Studies that had selected participants on the basis of unrelated diagnoses or injuries were excluded. We performed multilevel, random-effects meta-analyses on 296 independent studies, including over four million (partly overlapping) individuals. We further explored developmental trajectories and the moderating roles of gender, measurement, geography and ancestry. We found all NDDs to be substantially heritable (family-based heritability, 0.66 (s.e. = 0.03); SNP heritability, 0.19 (s.e. = 0.03)). Meta-analytic genetic correlations between NDDs were moderate (grand family-based genetic correlation, 0.36 (s.e. = 0.12); grand SNP-based genetic correlation, 0.39 (s.e. = 0.19)) but differed substantially between pairs of disorders. The genetic overlap between NDDs and DICCs was strong (grand family-based genetic correlation, 0.62 (s.e. = 0.20)). While our work provides evidence to inform and potentially guide clinical and educational diagnostic procedures and practice, it also highlights the imbalance in the research effort that has characterized developmental genetics research.

Web-Based Exercise Interventions for Children with Neurodevelopmental Disorders

Various studies have shown the effectiveness of motor interventions for children with neurodevelopmental disorders (NDDs). Web-based interventions may provide an opportunity for remote access to effective interventions with less burden on therapists. This systematic review aimed to examine the effects of web-based exercise interventions for children with NDDs. We searched PubMed for relevant articles published in English since 1994 and included intervention studies focusing on NDDs in children aged ≤18 years, who received web-based exercise interventions. We categorized the extracted information by outcome measure and intervention type and assessed the risk of bias of the included studies. We selected five articles whose subjects had autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and developmental coordination disorder (DCD). The exercise interventions used active video games, a Zoom-based intervention, and a WhatsApp-based intervention. Three papers showed improvements in physical activity, motor function, and executive function, whereas two papers on DCD showed no improvements in motor coordination or physical activity. Web-based exercise intervention for children with ASD and ADHD may improve their motor function, executive function, and physical activity rather than for children with NDDs. An intervention may be more effective when the content of the intervention is based on objectives and symptoms, when guidance is provided by specialists, or when sufficient explanation and support are provided to parents. However, more research is needed to statistically evaluate the effectiveness of web-based exercise interventions for children with NDDs.

Non-pharmacological interventions for autistic children: An umbrella review

LAY ABSTRACT

What is already known about the topic?The delivery of evidence-based interventions is an important part of the clinical pathway for many autistic children and their families. However, parents, practitioners, and policymakers face challenges making evidence informed decisions, due to the wide variety of interventions available and the large, and often inconsistent, body of evidence regarding their effectiveness.What this paper adds?This is a comprehensive umbrella review, also known as a 'review of reviews', which examined the range of interventions available, the evidence for their effectiveness, and whether effects were influenced by factors relating to individual children (e.g. chronological age, core autism characteristics, and related skills) or the ways interventions were delivered (by whom and in what setting, format, mode, and amount). There was evidence for positive therapeutic effects for some, but not all, interventions. No single intervention had a positive effect for all child and family outcomes of interest. The influence of child and delivery characteristics on effects was unclear.Implications for practice, research, and policyThe findings provide parents, practitioners, and policymakers with a synthesis of the research evidence to inform decision-making and highlight the importance of individualised approaches in the absence of clear and consistent evidence. The findings also highlight the need to improve consistency and completeness in reporting of research studies, so that the same questions may be answered more comprehensively in the future.

Assessing diversity and inclusivity is the next frontier in mental health recovery narrative research and practice (Preprint)

Demand for digital health interventions is increasing in many countries. The use of recorded mental health recovery narratives in digital health interventions is becoming more widespread in clinical practice. Mental health recovery narratives are first-person lived experience accounts of recovery from mental health problems, including struggles and successes over time. Helpful impacts of recorded mental health recovery narratives include connectedness with the narrative and validation of experiences. Possible harms include feeling disconnected and excluded from others. Diverse narrative collections from many types of narrators and describing multiple ways to recover are important to maximize the opportunity for service users to benefit through connection and to minimize the likelihood of harm. Mental health clinicians need to know whether narrative collections are sufficiently diverse to recommend to service users. However, no method exists for assessing the diversity and inclusivity of existing or new narrative collections. We argue that assessing diversity and inclusivity is the next frontier in mental health recovery narrative research and practice. This is important, but methodologically and ethically complex. In this viewpoint, we propose and evaluate one diversity and two inclusivity assessment methods. The diversity assessment method involves use of the Simpson Diversity Index. The two inclusivity assessment methods are based on comparator demographic rates and arbitrary thresholds, respectively. These methods were applied to four narrative collections as a case study. Refinements are needed regarding a narrative assessment tool in terms of its practicality and cultural adaptation.

What adults with ADHD want to know: A Delphi consensus study on the psychoeducational needs of experts by experience

Introduction

A lack of knowledge about attention‐deficit/hyperactivity disorder (ADHD) can contribute to feelings of distress and difficulty in seeking and accepting an ADHD diagnosis. The present study uses a Delphi consensus design to investigate the psychoeducational needs of adults with ADHD and the information about ADHD they would like included in digital health interventions for adults with ADHD. Inclusion of perspectives of service users in developing such interventions ensures that they are evidence based and addresses the risks of engagement barriers.

Methods

The expert panel consisted of 43 adults with ADHD (age range: 23–67 years). Panel members were asked to rate the importance of the proposed topics and provide additional suggestions. Suggested topics and topics that did not achieve consensus were included for ranking in the second round.

Results

Interquartile ratings were used to determine consensus. A high consensus was achieved in both rounds, with an agreement on 94% of topics in the first round and 98% in the second round. Most topics were rated as important or essential.

Conclusions

The findings highlighted that adults with ADHD want to learn about many different aspects of ADHD and the importance of considering their perspectives when developing psychosocial interventions. Findings can be applied when creating psychoeducational content for adult ADHD.

Patient or Public Contribution

Adults with ADHD were recruited to the Delphi panel to use an experts‐by‐experience approach. In doing so, we are engaging service users in the development of a psychoeducational smartphone app. The evaluation of the app will involve interviews with app users. Additionally, the present study was developed and conducted with ADHD Ireland, a charity based in Ireland that advocates for people with ADHD.

Behavioral Change Factors and Retention in Web-Based Interventions for Informal Caregivers of People Living With Dementia: Scoping Review

BACKGROUND

Web-based interventions aimed at supporting informal caregivers of people living with dementia have the potential to improve caregivers' well-being and psychological health. However, few interventions are widely implemented for this population, and none of the prior reviews have systematically examined the use of behavior change techniques (BCTs), theories, and agents in web-based interventions for informal caregivers of people living with dementia. To better understand this implementation gap, we reviewed the literature to map behavioral factors (BCTs, theories, and agents) deployed in the studies. Furthermore, because there is an emerging consensus that retention could be shaped by participant characteristics and behavioral factors, we explored relationships between these features and retention rates across studies.

OBJECTIVE

We pursued 3 objectives: to map behavioral factors involved in the web-based interventions for informal caregivers of people living with dementia; to examine the relationship between behavioral change elements and retention in the studies; and to examine the relationship between participant characteristics (gender, age, and spouse or adult children caregiver proportion) and study retention.

METHODS

We conducted a literature review using the following keywords and their corresponding Medical Subject Headings terms: dementia, caregivers, and web-based intervention. The time limits were January 1998 to March 2022. Using the BCTv1 taxonomy, which specifies active behavioral components in interventions, 2 coders collected, summarized, and analyzed the frequency distributions of BCTs. Similarly, they abstracted and analyzed participant characteristics, behavior change theories, behavior change agents, and retention rates in the studies.

RESULTS

The average age was 61.5 (SD 7.4) years, and the average proportion of spousal informal caregivers, adult children informal caregivers, and retention rates were 51.2% (SD 24.8%), 44.8% (SD 22%), and 70.4% (SD 17%), respectively. Only 53% (17/32) of the studies used behavior change theories, but 81% (26/32) included behavior change agents. The most common BCTv1 clusters were shaping knowledge and social support. The median number of BCTv1 clusters was 5 (IQR 3). We observed a negative correlation between the proportion of spousal informal caregivers and the retention rate (r=-0.45; P=.02) and between the number of BCTv1 clusters and retention rates (r=-0.47; P=.01). We also found that the proportion of adult children informal caregivers in the study was significantly and positively correlated with the retention rate (r=0.5; P=.03). No other participant characteristics or behavioral factors were associated with retention rates.

CONCLUSIONS

We found that almost half of the studies were not informed by behavior change theories. In addition, spousal involvement and a higher number of BCTs were each associated with lower retention rates, while the involvement of adult children caregivers in the study was associated with higher retention. In planning future studies, researchers should consider matching participant characteristics with their intended intervention as the alignment might improve their retention rates.

Online randomised trials with children: A scoping review protocol

Introduction: This scoping review will determine how online, randomised trials with children are conducted. The objectives of the review are: (a) to determine what methods and tools have been used to create and conduct online trials with children and (b) to identify the gaps in the knowledge in this field. Over the last decade, randomised trials employing online methods have gained traction. Decentralised methods lend themselves to certain types of trials and can offer advantages over traditional trial methods, potentially increasing participant reach and diversity and decreasing research waste.  However, decentralised trials that have all aspects of the trial exclusively online are not yet common, and those involving children even less so. This scoping review will describe and evaluate the methods used in these trials to understand how they may be effectively employed. Methods: Methods are informed by guidance from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. The search strategy was developed in consultation with an information specialist for the following databases: MEDLINE, CENTRAL, CINAHL, and Embase. Grey literature searches will be completed with the consultation of experts in decentralised trials and digital health using internet searches and suitable trial registries. Once identified, included full-text studies’ references will be manually searched for any trials that may have been missed. We will include randomised and quasi-randomised trials conducted exclusively online with participants under the age of 18 published in English. We will not limit by country of conduct or date of publication. Data will be collected using a data charting tool and presented in text, graphical, and tabular formats. Ethics and Dissemination: Ethical approval is not needed since all data sources used are publicly available. The review will be available as a preprint before publication in an open-access, peer-reviewed journal.

Internet-Based Prevention Program of Victimization for Youth in Care and Care Leavers (EMPOWER YOUTH): Protocol for a Randomized Controlled Trial

BACKGROUND

The global estimate of the number of children in institutional care is around 5 million, with around 1 million of these children living in Europe. In Germany, about 75,000 children and adolescents find themselves in the foster care system and about 93,000 additional children and adolescents are living in institutions. Traumatic experiences and neglect in childhood are highly prevalent among these youth in care and are related to severe long-term effects. Childhood maltreatment and abuse can increase the risk of future victimization experiences. Although youth in care are at risk of victimization or revictimization, no specific evidence-based prevention program has been designed to address these specific needs.

OBJECTIVE

This study aims to evaluate the efficacy of a newly developed 6-module internet-based prevention program of victimization for youth in care, named EMPOWER YOUTH.

METHODS

In a randomized controlled trial, the intervention group will be compared to a waiting-list control group with an unblinded 1:1 allocation ratio. Assessments will take place before randomization (baseline) and at follow-up 18 weeks after baseline (ie, 12 weeks after finishing the last module of the program). The primary endpoint is the number of victimization, and online and offline bullying experiences (composite score) at the 18-week follow-up. Secondary endpoints are risk-taking behavior, aggressive tendencies, empathy, prosocial behavior, depressiveness, and loneliness at follow-up. The expected outcome requires a sample size of 156 subjects to achieve a power of 80%. Assuming a 30% dropout rate at follow-up, we require 225 participants to be allocated to the trial. Participants are youth in care, that is, adolescents in foster care, adopted adolescents, or young care leavers aged 14 to 21 years.

RESULTS

Ethical approval was granted by the Ethics Committee of the Medical School Berlin in March 2021 (MSB-2021/55). Recruitment started in September 2021 and is planned until November 2022. The results are expected to be published in January 2023.

CONCLUSIONS

Given the increased likelihood for future victimization experiences among youth in care, there is a strong need for a low-threshold intervention specifically for this high-risk age group. There are no existing nationwide mental health programs exclusively for youth in care in Germany.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024749; https://tinyurl.com/tjaahayw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34706.

ADHD Comorbidity Structure and Impairment: Results of the WHO World Mental Health Surveys International College Student Project (WMH-ICS)

OBJECTIVE

To examine the prevalence of ADHD and the association of comorbid disorders, and multivariate disorder classes with role impairment in college students.

METHOD

About 15,991 freshmen (24 colleges, 9 countries, WMH-ICS) (response rate = 45.6%) completed online WMH-CIDI-SC surveys for 6-month ADHD and six 12-month DSM-IV disorders. We examined multivariate disorder classes using latent class analysis (LCA) and simulated a population attributable risk proportions (PARPs) of ADHD-related impairment.

RESULTS

About 15.9% had ADHD, of which 58.4% had comorbidities. LCA classified ADHD respondents to pure (42.9%), internalizing (36.0%), bipolar comorbidities (11.3%), and externalizing disorder classes (9.8%). ADHD, comorbidities, and multivariate disorder classes independently predicted severe impairment. PARPs: eliminating ADHD hypothetically reduced severe impairment by 19.2%, 10.1% adjusted for comorbidities, 9.5% for multivariate disorder classes.

CONCLUSIONS

ADHD and comorbid disorders are common and impairing in college students. Personalized transdiagnostic interventions guided by multivariate disorder classes should be explored.

Computerized Cognitive Behavioral Therapy for Treatment of Depression and Anxiety in Adolescents: Systematic Review and Meta-analysis

Background

Depression and anxiety are major public health concerns among adolescents. Computerized cognitive behavioral therapy (cCBT) has emerged as a potential intervention, but its efficacy in adolescents remains unestablished.

Objective

This review aimed to systematically review and meta-analyze findings on the efficacy of cCBT for the treatment of adolescent depression and anxiety.

Methods

Embase, PsycINFO, and Ovid MEDLINE were systematically searched for randomized controlled trials in English, which investigated the efficacy of cCBT for reducing self-reported depression or anxiety in adolescents aged 11 to 19 years. Titles, abstracts, and full texts were screened for eligibility by 2 independent researchers (TB and LC). A random-effects meta-analysis was conducted to pool the effects of cCBT on depression and anxiety symptom scores compared with the control groups. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool.

Results

A total of 16 randomized controlled trials were eligible for inclusion in this review, of which 13 (81%) were included in the meta-analysis. The quality of the studies was mixed, with 5 (31%) studies rated as good overall, 2 (13%) rated as fair, and 9 (56%) rated as poor. Small but statistically significant effects of cCBT were detected, with cCBT conditions showing lower symptom scores at follow-up compared with control conditions for both anxiety (standardized mean difference −0.21, 95% CI −0.33 to −0.09; I2=36.2%) and depression (standardized mean difference −0.23, 95% CI −0.39 to −0.07; I2=59.5%). Secondary analyses suggested that cCBT may be comparable with alternative, active interventions (such as face-to-face therapy or treatment as usual).

Conclusions

This meta-analysis reinforces the efficacy of cCBT for the treatment of anxiety and depression and is the first to examine this exclusively in adolescents. Future research could aim to identify the active components of these interventions toward optimizing their development and increasing the feasibility and acceptability of cCBT in this age group.

Trial Registration

PROSPERO CRD42019141941; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141941

A Pilot Exploratory Study to Form Subgroups Using Cluster Analysis of Family Needs Survey Scores for Providing Tailored Support to Parents Caring for a Population-Based Sample of 5-Year-Old Children with Developmental Concerns

In a population-based developmental screening program, healthcare providers face a practical problem with respect to the formation of groups to efficiently address the needs of the parents whose children are screened positive. This small-scale pilot study explored the usefulness of cluster analysis to form type-specific support groups based on the Family Needs Survey (FNS) scores. All parents (N = 68), who accompanied their 5-year-old children to appointments for formal assessment and diagnostic interviews in the second phase of screening, completed the FNS as part of a developmental questionnaire package. The FNS scores of a full dataset (N = 55) without missing values were subjected to hierarchical and K-means cluster analyses. As the final solution, hierarchical clustering with a three-cluster solution was selected over K-means clustering because the hierarchical clustering solution produced three clusters that were similar in size and meaningful in each profile pattern: Cluster 1-high need for information and professional support (N = 20); Cluster 2-moderate need for information support (N = 16); Cluster 3-high need for information and moderate need for other support (N = 19). The range of cluster sizes was appropriate for managing and providing tailored services and support for each group. Thus, this pilot study demonstrated the utility of cluster analysis to classify parents into support groups, according to their needs.

An Internet Based Intervention for Adults With Autism Spectrum Disorder-A Qualitative Study of Participants Experiences

Background: Adults with autism spectrum disorder face several barriers to accessing evidence-based care, including difficulties in communicating needs, social anxiety or in traveling to a health care unit. In recent years, several forms of internet-based treatments have shown to be effective for a variety of psychiatric conditions. Internet-based treatment alternatives allow convenient and flexible formats, and therefore have the potential to increase access to health care for individuals with autism spectrum disorder. However, knowledge about how internet-based treatment features may suit the needs of individuals with autism is limited. The aim of this study was to explore the participant experiences of an internet-based intervention for adults with autism spectrum disorder. The primary focus of the investigation was on autism-specific needs in relation to the features unique to the online format. Methods: In this qualitative study, semi-structured telephone interviews were conducted with 14 participants who had completed a text-based internet-based intervention for adults with autism spectrum disorder. We used an inductive approach and analyzed the data using qualitative content analysis. Results: Five main categories were identified: (1) implications of the online format, (2) the fixed non-individualized model, (3) therapist interaction, (4) interacting with other participants, and (5) making use of the treatment content. Overall, participants appreciated the availability and that they could work on their treatment independent of time or location. Among those participating in group-based chat-sessions with the other participants, it was considered a generally positive experience. Furthermore, most participants felt safe and relaxed in relation to the therapist and appreciated the text-based format. However, several participants felt that the format and content of the treatment was not sufficiently adapted to their individual life situation. Conclusion: In conclusion, this internet-based treatment constitutes an accessible and energy-saving treatment alternative for adults with autism. Further, integrating group-based components seems feasible in an otherwise individual internet-based treatment for individuals with autism. However, group-based components do require a clear purpose and rationale. Future studies should develop and evaluate treatment adaptations tailored to individual needs.

Targeting hostile attributions in inclusive schools through online cognitive bias modification: A randomised experiment

The tendency to make hostile attributions in ambiguous social situations has been associated with aggression and may be targeted through cognitive bias modification for interpretations (CBM-I). Despite their high prevalence of aggression and internalising problems, children and young people with neurodevelopmental disorders (NDD) or special educational needs (SEN) are markedly absent from CBM-I studies. This pilot study investigates whether online CBM-I can reduce hostile attributions and reactive aggression in inclusive school pupils. In Study 1, 71 pupils (mean age = 12.2, SD = 1.5; 25.4% presented with NDD or SEN) were randomly allocated to complete three sessions of either CBM-I (n = 37) or active control training (n = 34). CBM-I involved interpreting ambiguous scenarios or faces in a non-hostile manner, whereas the control training involved attention and memory exercises without resolving ambiguity. Between-group comparison showed CBM-I to reduce both hostile attributions and reactive aggression. In Study 2, follow-up focus groups with 23 pupils demonstrated the acceptability of training content and delivery. Together, these findings show online CBM-I to be acceptable and effective at reducing both hostile attributions and reactive aggression in an inclusive setting. The possibility of intervention effects on behavioural outcomes and potential confounding variables require further investigation.

A Pilot Study of a Parent-Mediated, Web-Based Motor Skill Intervention for Children With Down Syndrome: Project SKIP

To inform the development of scalable and sustainable fundamental motor skill interventions for children with Down syndrome, this study examined the feasibility and preliminary effectiveness of Project Skill Intervention Implemented by Parents (Project SKIP), a web-based, parent-mediated intervention intended to improve ball skills among children with Down syndrome. Twenty-four families enrolled in the study (including 13 boys and 11 girls; Mage = 4.92). Fourteen children were assigned to an experimental group and participated in the 6-week intervention, and 10 children served as the inactive comparison group. The Test of Gross Motor Development-3 was administered preintervention and postintervention. In addition, parents of children in the experimental group completed a postintervention survey to assess their perceptions of Project SKIP. Following the intervention, there was a significant improvement in ball skills (p = .023, d = 0.86) for children in the experimental group, whereas the comparison group did not show significant improvement. Moreover, parents perceived Project SKIP to be feasible and effective; all parents reported being satisfied with their overall experience in the program, and 11 parents indicated that their child's fundamental motor skills were positively influenced by the intervention. Engagement was high, with the majority of parents (n = 8, 57%) interacting with Project SKIP content three to four times a week.

Efficacy of parent-mediated communication-focused treatment in toddlers with autism (PACT) delivered via videoconferencing: a randomised controlled trial study protocol

INTRODUCTION

Intervention in the preschool period is currently recommended for autism spectrum disorder. Therapies delivered by parents are particularly suitable for young children. Preschool Autism Communication Trial (PACT) is a parent-mediated therapy that has shown a significant and sustained impact on autism symptom reduction. However, access to such evidence-based therapies for families is limited due to autism centres located in large urban areas. Using videoconferencing to deliver PACT training to parents may improve accessibility for families living in underserved areas.

METHODS AND ANALYSIS

This single-blind randomised controlled trial, involving six sites in France, will investigate the efficacy of a telehealth, videoconferencing-based, parent-mediated PACT therapy on autism symptoms, over a 12-month period. It will compare PACT plus treatment as usual (TAU) against TAU only in a cohort of 238 toddlers (119 per group) aged 18-36 months at inclusion and living with their families more than 40 min away from the specialist centres for autism. Primary outcome will include change of overall autism score on the Autism Diagnostic Observation Scale (ADOS) at 12 months. Secondary outcomes will measure change in child skills, child functioning, impact on parents (stress, health, priorities) and implementation characteristics. Repeated measures analyses will be used to test the effect of PACT intervention on the overall ADOS module 1 score over the 12-month study period. Linear mixed models will be used with time, treatment allocation and the interaction between treatment and time as fixed effects and individual variation as random effect.

ETHICS AND DISSEMINATION

This protocol (V.5, date: 25 October 2019) is approved by the French National Review Board (reference no 2018-A02516-49). The results will be disseminated via peer-reviewed journals TRIAL REGISTRATION NUMBER: NCT04244721.

Internet-based versus face-to-face intervention training for parents of young children with excessive screen-time and autism spectrum disorder-like symptoms: a comparative study

Internet-based intervention approach is one novel strategy to train. However, only a few clinical trials have compared internet-based parent training intervention with an equal face-to-face intervention for children with autism spectrum disorder (ASD)-like symptoms. The primary aim of this study was to compare treatment outcomes of an internet-based intervention with a face-to-face intervention for young children with excessive screen-time and ASD-like symptoms. A total of 40 mother-young children with excessive screen-time and ASD-like symptoms dyads were assigned to the Internet-based (n = 20) and to the face-to-face intervention (n = 20). Parents in both groups received intervention that involves 7 sessions (one session per week). Primary outcome measures were the Gilliam autism rating scale - second edition (GARS-2), repetitive behavior scale- revised (RBS-R) and parenting stress index (PSI). The analysis yielded no significant between-group difference for any of the pre- to post-intervention measurements. At post-intervention both intervention conditions revealed significant symptoms changes compared to before the intervention. Also, the parental stress was significant related to the child's autism symptoms and repetitive behaviors severity. Internet-based parent training intervention for young children with excessive screen-time and ASD-like symptoms and their parents is equally beneficial to regular face-to-face parent training intervention. These findings support the potential for using telehealth to provide research-based parent training interventions to any family that has access to the Internet.

Characteristics of the Users of Troubled Desire, a Web-Based Self-management App for Individuals With Sexual Interest in Children: Descriptive Analysis of Self-assessment Data

BACKGROUND

Despite the high prevalence of child sexual offenses and the increasing amounts of available child sexual abuse material, there is a global shortage of preventive interventions focusing on individuals at risk of sexual offending. The web-based app Troubled Desire aims to address this shortage by offering self-assessments and self-management training modules in different languages to individuals with sexual interests in prepubescent and early pubescent children (ie, those with pedophilic and hebephiliac sexual interest, respectively).

OBJECTIVE

The aim of this study was to describe the characteristics of the users of the Troubled Desire app.

METHODS

The fully completed self-assessment data gathered within the first 30 months of this study from October 25, 2017 to April 25, 2020 were investigated. The main outcome measures were (1) sociodemographic information and (2) sexual interests and sexual behaviors of the users of Troubled Desire.

RESULTS

The self-assessment was completed by 4161 users. User accesses were mainly from Germany (2277/4161, 54.7%) and the United States (474/4161, 11.4%). Approximately 78.9% (3281/4161) of the users reported sexual interest in children; these users were significantly more likely to report distress and trouble owing to their sexual interest. Further, child sexual offenses and consumption of child sexual abuse material were significantly more common among users with sexual interest in children than among users with no sexual interest in children. Additionally, the majority of the offenses were not known to legal authorities.

CONCLUSIONS

The Troubled Desire app is useful in reaching out to individuals with sexual interest in prepubescent and early pubescent children. However, future research is warranted to understand the prospective relevance of the Troubled Desire app in the prevention of child sexual offending.

Efficacy of a Web-Enabled, School-Based, Preventative Intervention to Reduce Bullying and Improve Mental Health in Children and Adolescents: Study Protocol for a Cluster Randomized Controlled Trial

Introduction: Bullying is a major preventable risk factor for mental disorders. Available evidence suggests school-based interventions reduce bullying prevalence rates. This study aims to test the efficacy of a web-enabled, school-based, multicomponent anti-bullying intervention to prevent school bullying and to assess its effects on mental health and quality of life. Methods and analysis: Cluster randomized controlled trial conducted in 20 publicly funded primary and secondary schools in Madrid, Spain. Schools are randomly allocated to either the intervention arm (n = 10) or conventional practices arm (n = 10). The web-enabled intervention (LINKlusive) lasts ~12 weeks and consists of three main components: (i) an online training program for teachers and parents, (ii) a web-guided educational program for students, focusing on promoting respect for diversity, empathy, and social skill development, and (iii) a web-guided, teacher-delivered, targeted intervention program for bullying situations identified based on peer-support strategies and individual intervention for those involved (i.e., bullying victims and perpetrators). The primary objective is to compare differences between peer-reported bullying victimization in the intervention and control arms at the end of the intervention. Secondary outcome measures are additional measures of bullying victimization and perpetration, mental health symptoms, self-esteem, and quality of life. A follow-up assessment is conducted 1 year after the end of the intervention. Treatment effects will be tested using multilevel mixed models, adjusting for school-, classroom-, and student-related covariates. Considering the increased bullying rates in children with special educational needs, a specific subgroup analysis will test the efficacy of the intervention on bullying prevalence, mental health, and quality of life in this particularly vulnerable population. Ethics and Dissemination: The Deontology Commission of the School of Psychology, Universidad Complutense in Madrid, Spain reviewed the study protocol and granted ethical approval on 21st January 2019. The results of the trial will be disseminated in relevant peer-reviewed journals and at conferences in the field. Trial Registration Number: ISRCTN15719015.

Social Cognitive Interventions for Adolescents with Autism Spectrum Disorders: A Systematic Review

INTRODUCTION

Autism spectrum disorder (ASD), a heterogeneous neurodevelopmental disorder, impacts social experience and functioning throughout the lifespan. Although the postnatal phase of neuroplasticity has been a focus for early interventions in ASD, a second critical period in adolescence has emerged as a promising target for experience-dependent remediation. Interventions addressing the multidimensional construct of social cognition have also shown potential as a therapeutic approach. Yet, to date, evidence-based social cognitive interventions (SCIs) designed for adolescents with ASD are still lacking. In this review, we aim to survey and synthesize the extant literature on SCIs for adolescents with ASD in order to inform next steps for treatment research.

METHODS

Using the PRISMA guidelines, we limited our queries to peer-reviewed, English-language journal articles describing SCI trials for adolescents with ASD using a randomized controlled design.

RESULTS

Eighteen articles in total met our inclusion/exclusion criteria. We present and discuss these trials using the non-exclusive categories of group-based social skills interventions, experiential-based interventions, and computer-assisted interventions.

LIMITATIONS

To ensure a focus on adolescence, we excluded trials with teen-age participants if mean subject age was not between 12-18 years. Also, given the variability across studies in outcome measures, study designs, samples, and effect sizes, findings were incommensurable.

CONCLUSIONS

Several reviewed SCIs reported post-treatment improvements in varied domains but findings were inconsistent. Further investigations of existing and novel interventions are warranted; attention to assessing and improving long-term skill transfer is essential. Technology-assisted augmentations may improve treatment efficacy and ecological validity of therapeutic gains.

Protocol for the Process Evaluation of the Online Remote Behavioural Intervention for Tics (ORBIT) randomized controlled trial for children and young people

BACKGROUND

Process evaluations are an important component in the interpretation and understanding of outcomes in trials. The Online Remote Behavioural Intervention for Tics (ORBIT) study is a randomized controlled trial evaluating the effectiveness of an Internet-delivered behavioural intervention (called BIP TIC) compared to an Internet-delivered education programme aimed at children and young people with tics. A process evaluation will be undertaken alongside the main trial to determine precisely how the behavioural intervention works and ascertain whether, and if so, how, the intervention could be successfully implemented in standard clinical practice. This protocol paper describes the rationale, aims, and methodology of the ORBIT trial process evaluation.

METHODS

The process evaluation will have a mixed-methods design following the UK Medical Research Council 2015 guidelines, comprising both quantitative and qualitative data collection. This will include analysing data usage of participants in the intervention arm; purposively sampled, semi-structured interviews of parents and children, therapists and supervisors, and referring clinicians of the ORBIT trial, as well as analysis of qualitative comments put into the online therapy platform by participants at the end of treatment. Qualitative data will be analysed thematically. Quantitative and qualitative data will be integrated in a triangulation approach, to provide an understanding of how the intervention works, and what resources are needed for effective implementation, uptake and use in routine clinical care.

DISCUSSION

This process evaluation will explore the experiences of participants, therapists and supervisors and referring clinicians of a complex online intervention. By contextualising trial efficacy results, this will help understand how and if the intervention worked and what may be required to sustain the implementation of the treatment long term. The findings will also aid in our understanding of factors that can affect the success of complex interventions. This will enable future researchers developing online behavioural interventions for children and young people with mental health and neurological disorders to gain invaluable information from this process evaluation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number, ISRCTN70758207. Registered on 20 March 2018. ClinicalTrials.gov, NCT03483493. Registered on 30 March 2018.