"Everyone will laugh at me." "Something is hiding in the dark." "If my mom goes out, she might not come back."
These are anxious thoughts that, for children with anxiety disorders, can interfere with their quality of life. Child anxiety disorders are common, affecting about one to two out of every 10 school-age children.
Researchers from the University of Pittsburgh Schools of Health Sciences, Jennifer Silk, an expert in child anxiety, and Bambang Parmanto, an expert in telehealth, have developed a promising new technology to enhance treatment for child anxiety disorders: a mobile health platform called SmartCAT. SmartCAT stands for smartphone-enhanced child anxiety treatment. The platform connects a smartphone app for patients with a clinician portal, allowing real-time communication between the two.
SmartCAT is intended to augment cognitive behavioral therapy, or CBT, an effective treatment for child anxiety disorders. Children undergoing CBT treatment typically meet once a week with a mental health professional to learn coping skills, such as how to identify thoughts that make them anxious and replace them with more appropriate thoughts.
"Our idea was that kids need to be working on this more than once a week," Ms. Silk said. "And if they could ... practice the skills in their daily life when they're actually experiencing anxiety, we thought that might be able to improve the treatment." Using a smartphone app to complement treatment was a natural choice, the researchers say, given kids' familiarity with technology.
Conventional CBT treatment typically lasts about four months, or 16 sessions. Research has shown that about 60 percent of children who complete treatment no longer have a diagnosis of anxiety disorder. With SmartCAT, the developers hope to increase that percentage and decrease treatment time.
A pilot study of the SmartCAT program involved nine young people ages 9-14 with an anxiety-related diagnosis. Three were given 16-session CBT; the remaining six were treated with a shortened eight-week course that combined CBT and SmartCAT. Four of the children in the combination program no longer have an anxiety diagnosis. This is similar to the response rate of children who underwent the longer CBT treatment. The young patients did actively use the app, so although the study is preliminary, it suggests children may get better faster when they use SmartCAT.
The heart of the SmartCAT app is a skills coach. A therapist develops a skills coach plan for each child. When kids are feeling anxious, they press the icon for the skills coach and answer questions about their feelings. The skills coach suggests coping thoughts and problem-solving strategies for the children to use in the moment.
"That's the key, being able to assess right then and there and ask the kids to practice when the symptom happens," Mr. Parmanto explained.
This poses a problem for children who experience anxiety in school, however, because most ban the use of cell phones. "We find that kids will often report on things that happened during school when they get home," Ms. Silk said. To account for that, the skills coach asks kids to think about how they handled the situation and whether there was a coping strategy they did not try that might have helped.
Working with the app, the other side of SmartCAT is the integrated clinician Internet portal. It allows a therapist to monitor the child's activity with the skills coach throughout the week, giving the clinician a clearer picture of the child's life than mere weekly meetings provide.
SmartCAT also allows messaging between the portal and smartphone; therapists can send the kids encouraging messages, and the children can share successes.
"We have a lot of kids who are nervous about going on sleepovers," Ms. Silk explained. "Whenever they successfully accomplish that, they like to send a little note to the therapist saying, 'I did it! I had a great time.' " This frequent interaction helps the children stay motivated to practice their skills.
Children are also motivated by the reward bank, which lets them earn digital points for using the app. They then redeem the points for small prizes like stickers and accessories.
The researchers are working on making the app even more appealing to children by adding interactive games. They are developing a game, Thought Buster, in which bubbles appear on screen that contain different thoughts. The aim is to pop the bubbles containing thoughts that lead to anxiety.
SmartCAT uses technology developed by Mr. Parmanto and his team called Active2. Active2 uses XMPP, a general protocol for communication between two or more parties. XMPP is not designed for reliability, however, so the Active2 technology makes the connection reliable and secure -- without draining the phone's battery. Additionally, Active2 has features that are important for mobile health. For example, if the smartphone is lost, the clinician can remotely erase data from it.
To date, 10 children in the 9-14 age group have completed treatment, and more are finishing up the therapy. The researchers are confident that SmartCAT enhances standard treatment.Once they have the data to back that up, they plan to make the technology widely available.
The researchers' next step is to conduct a large-scale randomized clinical trial. They have applied for funding from the National Institutes of Health and, if they get the grant, "We'll be in a position to provide free treatment to families in the Pittsburgh area, which would include the CBT plus the use of the app," Ms. Silk said. The researchers hope to conduct the study in 2014.
For information, contact study coordinator Marcie Walker, Walkerml2@upmc.edu or 412-383-5425.health
Kathryn Sterling: firstname.lastname@example.org.