Child anxiety is increasingly common and difficult to treat. Researchers recently evaluated the quality of popular apps available for child anxiety and whether they follow evidence-based treatment strategies.
Child anxiety is becoming increasingly prevalent. Anxiety disorders are the most common mental disorders in children in the USA and are usually the first mental illness to present. They often manifest in children as young as six years of age. Nearly one-third of adolescents will experience an anxiety disorder before the age of 18 years. Child anxiety has been linked to poor outcomes in adulthood including an increased risk of other mental illnesses, substance use, suicidal behaviour, and a reduced quality of life.
Cognitive behavioural therapy is a gold standard for child anxiety
Cognitive behavioural therapy (CBT) is the gold standard for treatment of child anxiety. This therapy has children and parents learn to recognize the relationship between their thoughts, feelings, and behaviours. Children are encouraged to create a hierarchy of situations that cause them fear and to systematically challenge themselves to tackle these experiences. Children are also encouraged to use cognitive strategies such as “realistic thinking” to examine whether a threat is real or perceived and to create realistic perceptions of danger and risk.
Barriers to accessing traditional therapy
There are many barriers to accessing traditional therapy, including stigma, long wait lists, cost, and transportation constraints. It is difficult for many people to access the therapy that is needed. Strategically designed mobile apps may be helpful for families struggling with child anxiety, by providing a useful daily therapeutic tool. Mobile apps that are developed by expert scientists and doctors and rigorously tested with clinical trials take many years to reach the consumer market. There has been, however, a proliferation of apps that are marketed to families struggling with depression that were developed instead by the tech industry.
A recent study published in Behavior Therapy evaluated the content of apps marketed to families struggling with child anxiety. Researchers from the Mental Health Interventions and Technology (MINT) program at Florida International University in the US completed a systematic search of the Google Play Store and the Apple Store and found 121 relevant apps. Each app was evaluated by their descriptive characteristics, mobile functionalities, and whether or not they adhere to evidence-based treatment principles. They also compared the quality of apps that cost money to apps that are free. The researchers hypothesized that the majority of the apps marketed to youth would not contain some or all of the key elements of effective treatment.
Industry-driven apps were insufficient
The study showed that the majority of the apps were available for free from the Google Play Store, with the most expensive app costing $6.99. They found that the average reading level was generally higher than the age that the app was marketed for. For example, many apps designated for those four years or older were written at a ninth-grade reading level. Additionally, the study showed that the majority of the apps had adequate privacy protections in place, and only one in six directed users to appropriate risk-management centres.
There were few technological features that the literature recommends available through these apps. None of the apps gathered data through sensors and fewer than 5% used ecological momentary assessments to evaluate mood or behaviour in real time. There were few apps that allowed users to customize their preferences or content.
The content of apps for child anxiety was not evidence-based
Only half of the apps included any evidence-based treatment components at all, and only 23% contained more than one. The most common evidence-based treatment method was “exposure”, which was present in only one-fifth of the apps. Psychoeducational information related to anxiety, generally considered an important element of CBT, was rare. Fewer than one-fifth of the apps referenced self-monitoring, reflection, or the tracking thoughts, feelings, or behaviours.
The researchers found that, instead of evidence-based approaches, the apps often contained distraction tools such as games or colouring activities. Roughly half of the apps included relaxation techniques, although these techniques are no longer emphasized in clinical practice. In general, the apps that cost money were more likely to contain content related to evidence-based treatment for child anxiety.
Challenges for anxiety apps
Researchers who are developing high-quality mobile apps for anxiety are facing several challenges. One is the content heavy nature of treatment, with a high component of education. Experience indicates that individuals tend to use apps in short bursts, meaning that content heavy apps may not align with user habits. As comprehensive treatment has many elements, which may seem overwhelming in app form, users may benefit instead from a single quality app that is dedicated to one practice element.
For example, an app could focus entirely on restructuring the negative thoughts that influence anxiety. Apps of this type could be paired, or grouped to reduce the complexity and increase compliance. Additionally, these single-quality apps could be paired with traditional treatment to increase overall effectiveness and compliance. The research will be required to evaluate whether a complementary group of single element apps or one single comprehensive app is more beneficial. Additionally, it is important to evaluate the effectiveness of these apps as a stand-alone feature or as an add-on to other forms of therapy.
Limitations of the study
There are some important limitations to this study. First, the authors chose the search terms based on what they considered an intuitive approach to seeking apps for child anxiety. They searched for commonly used words such as “anxiety” and “stress”, however little is actually known about how parents search for and find these apps. It is therefore possible that the search was not actually reflective of the true experience of families. Importantly, several notable evidence-based apps were missing from these searches, in spite of being available on both Google Play and the Apple Store. It is not understood why these scientifically derived and medically endorsed apps did not appear in the top thirty apps for any relevant keyword search, as the mechanics of searches in apps stores is relatively unknown.
This is the first study to examine the content of apps marketing to the children and families struggling with child anxiety. The scientists found few comprehensive and useful apps. Instead, the study revealed that the majority of the apps were lacking important components and few of the apps relied on evidence-based treatment principles. This study demonstrates that there is a clear need to develop more comprehensive self-management apps that use multiple evidence-based strategies to manage child anxiety. Fortunately, several large high profile studies are currently underway to develop these tools.
Written by Lisa Borsellino, B.Sc.
References: Bry, Laura Jane, et al. “Consumer Smartphone Apps Marketed for Child and Adolescent Anxiety: A Systematic Review and Content Analysis.” Behavior Therapy (2017).