Behavioral Therapy for Anxious Youth - Springer Link

J Rat-Emo Cognitive-Behav Ther (2014) 32:57–66 DOI 10.1007/s10942-014-0184-5

The Emerging Role of Technology in Cognitive– Behavioral Therapy for Anxious Youth: A Review Rebecca Rialon Berry • Betty Lai

Published online: 1 February 2014 Ó Springer Science+Business Media New York 2014

Abstract Research documents the application of cognitive–behavioral therapy (CBT) with technology either as therapeutic adjuncts or stand-alone interventions. The literature evaluating the feasibility and efficacy of using technology with CBT for youth experiencing internalizing disorders is small though steadily emerging. Technological approaches offer cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. The present article aims to review the use of two broad types of technology in CBT for anxious children and adolescents: computer- and internet-based CBT and mobile mental health applications (i.e., mobile phone, smartphone, and tablet technology). Within each section, we provide an overview of the advantages and general principles of each type of technology, and review evidence for the use of each type of technology along with examples of current applications. Finally, we discuss ethical issues, barriers, and future directions for the use of technology in facilitating dissemination of effective treatments. Keywords

Technology Cognitive–behavior therapy Youth Anxiety

Cognitive Behavioral Therapy (CBT) is highly effective in treating anxiety disorders among youth (Cartwright-Hatton et al. 2004; Ollendick and King 1998). However, few youth with anxiety disorders receive treatment from mental health professionals (Chavira et al. 2005; Essau et al. 1999; Merikingas et al. 2010). Most R. R. Berry (&) Early Life Stress and Pediatric Anxiety Program, Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, 401 Quarry Rd., Stanford, CA 94305, USA e-mail: [email protected] B. Lai School of Public Health, Georgia State University, Atlanta, GA, USA

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youth are very comfortable with technology and use platforms such as computers, mobile phones, and tablets, frequently. Current estimates from the Pew Research Institute indicate that 95 % of youth use the internet, 93 % have a computer at home, and 78 % have mobile phones (Madden et al. 2013). Using technology in conjunction with CBT for youth is desirable because of contained costs, via reduced therapist contact time (Newman et al. 1997), therefore offering increased convenience for both the therapist and client (Anderson et al. 2005). Technology shows promise in improving standardization and increasing treatment adherence (Heimberg and Coles 1999), and contributing to better dissemination of evidencebased interventions to underserved populations (Bouchard et al. 2000). Given the potentially important advantages of utilizing technology in conjunction with CBT for anxious youth, interest in the development of computer- and internetadministered assessments and treatments trended upward over the last decade (e.g., Boschen 2009a, b; Smith et al. 1999). At the same time, researchers and clinicians devote attention to improving the quality and reach of psychotherapies through the use of tablets and Smartphone applications (Boschen, 2009a; Kazdin and Blase 2011). However, evidence documenting the feasibility and efficacy of using technology with youth is limited, although emerging (Kendall et al. 2011). The goal of this article is to review the use of technology in CBT for anxious youth. In particular, we focus on two broad types of technology: computer- and internet-based CBT and mobile mental health applications (i.e., mobile phone, smartphone, and tablet technology). Within each section, we provide an overview of the advantages and general principles of each type of technology, and then review evidence for the use of each type of technology along with examples of current applications. Finally, we discuss ethical issues, barriers, and future directions for the use of technology in facilitating dissemination of effective treatments.

Computer- and Internet-Based Cognitive–Behavioral Treatments CBT, as opposed to other therapeutic modalities, is particularly well suited for delivery by computer or through the internet because CBT is highly structured and typically implemented in a sequential fashion (Anderson et al. 2005; Heimberg and Coles 1999; Proudfoot et al. 2004). General advantages of computer- or internetbased CBT include increased mastery and control for the user, accessibility, privacy, convenience, and reproducibility (Greist et al. 2000). All of these advantages are highly valued by adolescents (Stallard et al. 2010). Computer- and internet-based CBT programs also provide a system for disseminating evidencebased mental health treatment in primary care settings while maintaining treatment fidelity, even when facilitated by novice clinicians (Craske et al. 2009). Furthermore, computer-based therapies promote self-monitoring, give systematic feedback to the user, and help with the development of coping skills. An additional advantage to utilizing computers or the internet is that some outcome measures are ‘‘built in’’ to the technology. Generally, computer- or internet-based CBT programs begin with a predetermined syllabus. The syllabus outlines the principles and methods of CBT in a series

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of lessons, usually with homework assignments and supplementary information. These programs utilize self-guided training, supported by reminders from a nonclinical technician or practice nurse, or guided by a clinician who makes telephone calls, sends emails or posts comments on a private forum. Given this general format, treatment fidelity is enhanced through computerized delivery (Andrews et al. 2010).

Evidence and Current Applications The efficacy of computer- and internet-based CBT for adults with anxiety disorders adults is supported by large trials (Proudfoot et al. 2004) and meta-analytic reviews (e.g. Kaltenthaler et al. 2008; Spek et al. 2007). Despite the relatively small evidence base evaluating computer-based programs for youth, the literature in this area is expanding. Recently, manualized empirically supported treatments targeting anxiety in school-age children were adapted to computer- or internet-based formats (Elkins et al. 2011). Examples include the BRAVE-Online program (March et al. 2009) and Camp Cope-a-Lot: The Coping Cat CD-ROM (CCAL; Khanna and Kendall 2008, 2010). The BRAVE-Online program is an internet-based program for children aged 7–14 years, consisting of 10 weekly sessions. Each session takes approximately 60 min to complete (Spence et al. 2008). These sessions are followed by two booster sessions at one and 3 months post treatment. Parents also complete six sessions in the child version of this program. CCAL is geared towards children aged 7–12 years with anxiety, social phobia, and/or generalized anxiety disorder (Khanna and Kendall 2008). In this program, the therapist is viewed as a necessary part of treatment, and the program cannot be completed without a therapist, who conducts six ‘‘independent’’ (i.e., not technology-based) exposure sessions. Randomized controlled trials evaluating the BRAVE-Online program (March et al. 2009; Spence et al. 2006), as well as CCAL (Khanna and Kendall 2010) provide support for the utility of computerized interventions with anxious youth. Results from the BRAVE-Online trial, in which participants were randomized to a partial internet condition, clinic condition, or wait list control, indicate that the partial internet treatment produced reductions in anxiety symptoms that were comparable with the clinical condition (Spence et al. 2006). Significantly greater reductions in anxiety symptoms were demonstrated by partial internet condition, when compared to the wait-list control group (Spence et al. 2006). Furthermore, child and parent measures of treatment satisfaction demonstrate high to moderate levels of consumer satisfaction with the program (March et al. 2009; Spence et al. 2006). A randomized controlled trial comparing CCAL to individual CBT and a control condition (where participants received computer-based education, support, and attention) yielded evidence for the efficacy of this treatment with a sample of 7–13-year-old anxious children. At post-treatment, 81 % of participants receiving the CCAL intervention no longer met criteria for their primary diagnosis, and gains were maintained at 3-month follow-up with no differences observed between children in individual treatment and children who completed CCAL (Khanna and Kendall 2010). In addition, therapist adherence to treatment

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was significantly higher for the CCAL condition compared to the individual CBT condition, and both children and parents rated CCAL as an acceptable form of treatment. Computerized CBT approaches are also adapted to address anxiety behaviors in adolescent samples. Examples include the Cool Teens CD-ROM (Cunningham et al. 2006, 2009) and BRAVE for Teenagers—ONLINE (Spence et al. 2011). Evaluations of both programs are promising. Wuthrich et al. (2012) examined the efficacy of the Cool Teens program with 23 youth ages 14–17 compared to a waitlist control group. Adolescents in the Cool Teens group experienced significant reductions in the total number of anxiety disorders, severity of the primary anxiety disorder, and average severity for all anxiety disorders. Spence et al. (2011) assessed the efficacy of the BRAVE for Teenagers—ONLINE program relative to clinicbased CBT and a wait list control condition, with 115 youth aged 12–18 years. Both the internet and clinic-based CBT conditions produced significantly greater reductions in clinician-rated anxiety and greater improvements in overall functioning than the wait list condition at the 12-week assessment point, with no significant difference between treatment formats.

Mobile Mental Health Applications: Mobile Phone, Smartphone, and Tablet Applications The use of wireless information technology in health applications is experiencing a tremendous boom, in part because of ballooning health care costs and the limitations of one-on-one therapy to meet the mental health needs of the population. In particular, mobile phone applications for health demonstrate rapid growth, and these applications provide opportunities to expand current care beyond the clinic. At the same time, youth are gaining increasing access to mobile phones, smartphones, and tablets. Among youth, 78 % of adolescents own a mobile phone, and 47 % of these adolescents own smartphones (Madden et al. 2013). Further, 23 % of adolescents own a tablet (Madden et al. 2013). There are several potential advantages to using these mobile mental health applications with youth within the context of CBT for anxiety. First, for youth with mobile or smart phones, access to these devices is near constant. For example, in a survey of American adolescents, 54 % reported texting on their mobile phones daily, and half of teens reported sending more than 50 text messages in 1 day (Lenhart et al. 2010). This provides an opportunity for clinicians to remind youth about homework (e.g., reminding youth about tracking events, cognitions, and feelings, or specific assignments from therapy sessions), as well as an opportunity to track progress, and an opportunity for youth to identify patterns in their own data. Mobile applications are useful in providing psychoeducation, identifying resources, and may open up avenues for two-way communication between the therapist and client (Luxton et al. 2011). Additional advantages of mobile, smartphone, and tablet technology include their relatively low cost, portability, near constant connectivity, programmability, ability to record information, ease of use, and acceptability (Ly et al. 2012) to both youth and parents.

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Evidence and Current Applications As noted in recent reviews on mobile interventions (e.g., Riley et al. 2011), technology is advancing so quickly that it is difficult for researchers to ‘‘keep pace’’ with development (Aguilera and Muench 2012). Studies using mobile phone-based text messaging have the most research basis using CBT techniques, but even these studies are limited to feasibility studies (Aguilera and Muench 2012). Evidencebased smartphone applications using behavioral and cognitive methods tend to be in development stages (Morris et al. 2010). Although further research is needed on mobile applications, they represent a promising method for creating novel and multiple models of mental health delivery, a crucial next step for evidence-based research (Kazdin 2011). Despite the limited evidence base for specific mobile mental health applications, several basic CBT tools are currently being repackaged into mobile formats. Therapists utilize these tools to generalize skills between the therapy office and an individual’s everyday environment. In this next section, we will discuss selfmonitoring applications, which may be used to reinforce skill learning and motivation. However, we note that we are not endorsing any specific mobile applications in this review. Given the large volume of applications available, we strongly recommend that readers perform their own search for items that meet the specific needs for you and your clients. Self-monitoring Self-monitoring, or tracking information over the course of treatment, is often an essential component of CBT (Association of Behavioral and Cognitive Therapies 2013). Self-monitoring accounts for a significant portion of the variance in behavior change outcomes (e.g., Michie et al. 2009). Numerous self-monitoring applications are currently available to track various domains, including sleep, mood, food intake, and alcohol use. For example, a search for mood selfmonitoring applications in the Apple iTunes store (with the query ‘‘mood tracker’’) returned 94 currently available mobile self-monitoring applications (as of August 13, 2013). One potential source that may help clinicians reference self-monitoring mobile applications is the Quantified-Self website (http:// quantifiedself.com/guide), which is designed to promote self-monitoring using self-report and automated tracking tools. Self-monitoring mobile applications offer several advantages as an adjunctive treatment for CBT for anxious youth. First, these applications help clients stay accountable for self-monitoring. For example, paper-and- pencil monitoring tools are often completed retrospectively by youth. When patients do not track their mood throughout the week, therapists often ask patients to recall their earlier mood states, but these data are typically inaccurate (Shiffman et al. 2008). In contrast, mobile applications allow individuals to track their feelings and behaviors in real time (Aguilera and Muench 2012), which may render this data more accurate. In addition, results from self-monitoring applications are often displayed graphically, providing clients with instant feedback, reducing therapist time spent reviewing

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outcomes, and also providing summarized reports over time. This is especially powerful in terms of showing clients their progress over time. Self-monitoring mobile applications are a potential asset to the cognitive–behavioral therapist because they are simple tools to enhance what we are already doing in our practices. In their review of information technology applications for CBT practitioners, Aguilera and Muench (2012) highlight examples of applications that are available for mood monitoring via mobile phone. Two featured applications include Mood 247 (www.mood247.com) and the T2 Mood Tracker. Mood247 utilizes text messaging to collect data and uploads mood data to a website. There is an option to share the with a health-care provider or therapist by the patient providing a code that allows one to view mood ratings over time. In addition to mood ratings, individuals append notes related to the mood rating, potentially adding information about thoughts, behaviors, settings, and emotions to be further discussed in a therapy session. The T2 Mood Tracker is a smartphone application developed by the National Center for Telehealth and Technology that allows for individuals to track their mood and emotional states.

Discussion Challenges and Limitations Despite recent widespread growth and interest in computer- and internet-based CBT interventions, as well as mobile health applications, several barriers to their use exist. For example, some therapists and clients seeking treatment simply do not like using computers or mobile phones for addressing emotional difficulties. Certain clients also find mobile technology invasive or cite concerns related to privacy (Proudfoot et al. 2010). Additional barriers include technical issues that the client and the therapist are unable to resolve. In addition, limited expertise with current technology platforms is an inhibiting factor to some therapists’ ability to individualize applications for clients to suit their preferences and needs. Further, many mental health professionals are concerned that technology will replace face-to-face therapy. While these barriers reduce adoption of technology in therapy, understanding them should also be used as an important part of maximizing the use of technology as adjunctive or stand-alone treatments. Several ethical issues must also be considered when examining the role of technology in one’s therapeutic practice. First, feelings of isolation may increase for clients when technology is adopted into the therapeutic relationship. In addition, limitations to clinician knowledge should always be considered when adopting computer- and internet-based interventions or mobile health applications. Clinicians should be careful to practice ‘‘only within the boundaries of their competence’’ (American Psychological Association 2003). Therapists must also pay careful attention to confidentiality HIPAA concerns. Further, clinicians must inform patients about how to use technology, and they must provide guidance regarding the

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limitations of their availability, and provide information about when they will monitor any messages that may be conveyed via technology. Future Directions Information regarding electronic provision of mental health services (i.e., behavioral telehealth; Nickelson 1996) was outside of the scope of the current review. It is important for cognitive–behavior therapists to consider the function and efficacy of activities related to behavioral telehealth (Jerome and Zaylor 2000; Koocher and Morray 2000; Laszlo et al. 1999; Maheu and Gordon 2000; VandenBos and Williams 2000), including replications of face-to-face therapeutic encounters via video conferencing technologies, and the use of telecommunications and information technology to provide access to behavioral health assessment and diagnosis (Laszlo et al. 1999). Additional consideration should be given to the utility of communication applications on the internet, such as e-mail, instant messaging, blogs, and chat rooms, which are becoming an important and familiar component of the lives of many adolescents (Subrahmanyam and Lin 2007). Advances in technology offer promise for isolating and identifying key mechanisms of change underlying CBT.

Conclusion Technology is a potentially powerful tool for increasing the impact of existing evidence-based interventions, when applied appropriately. Technology may allow individuals with low access to in-person mental health services (e.g., those without transportation, those with limited money for mental health, those in rural settings, youth after disasters) to gain access to interventions. For example, studies have already demonstrated feasibility and acceptability utilizing SMS as a monitoring adjunct to CBT in a low-income, ethnically diverse population (Aguilera and Munõz 2011). These patients expressed being more aware of their mood states as well as feeling a sense of support and feeling cared for by their therapist. Rather than reducing therapeutic alliance, mobile interventions would allow providers to extend the reach of therapy beyond the walls of the clinic when clients are likely in need of more support. Scientists and practitioners should carefully assess the respective needs of clients and health care providers, and identify each technology’s strengths and limitations, to best determine how technology can meet those needs. This approach increases the likelihood that the technology will have staying power for mental health professionals. Furthermore, therapists should evaluate the pragmatic and clinical utility of technology in their own practices. In summary, computer- and internet-based treatments as well as mobile health applications offer a promising new area of investigation in the field of child anxiety research. The decision about which modality should occur on a case-by-case basis, taking into account such variables as the disorder being treated, the technology available to participants, their ease and facility with that technology, and security and privacy issues.

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