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Helping Kids Manage Anxiety—With an App

According to the National Alliance on Mental Illness, anxiety is the most common mental health concern in the United States and also tends to start early in life, often leading to depression, substance abuse and other mental health problems.

Pitt researchers have developed a tool that helps kids and adolescents better manage their anxiety. And now, they’re working with Pitt’s Innovation Institute, local pediatrics offices and schools to make it widely available to the public.

Mr. Rogers' legacy: Commitment to child development

Decades ago, Fred Rogers went on TV and began helping children understand and tak about their feelings in a way that was unusual for its time.

For Pitt researchers Jennifer Silk and Bambang Parmanto, a desire to help today's kids resulted in  a smartphone-enhanced child anxiety treatment—“a therapist in your pocket,” as Parmanto describes it.

The SmartCAT project is just one example of how Pitt researchers and educators are representing the commitment to child development that Rogers espoused.

"Our work continues on Mr. Rogers' basic theme of caring for children’s feelings,” Silk said.

Read more about the friendship and collaboration between Rogers and Margaret B. McFarland, Rogers' mentor and a child psychologist at Pitt, in PItt Med magazine.

SmartCAT, or, smartphone-enhanced child anxiety treatment, is a mobile health app designed to make treatment for anxiety disorders in children more effective and more efficient. It comes with an integrated clinician portal that allows patients to share their progress with their doctor.

Currently, cognitive behavioral therapy, or CBT, is a respected standard treatment for all types of anxiety, including generalized, separation and social anxiety. It works by having a therapist and patient work together on restructuring negative or intrusive thought patterns—first by identifying them, figuring out their triggers and then working up to actually changing the patient’s thinking through lived experiences or practicing exposures.

“We find that actually doing these exposures and facing your fears is what’s most effective in helping children and teenagers, as well as adults, get over their anxiety,” said Jennifer Silk, professor of psychology at Pitt and the lead investigator behind SmartCAT.

Studies have shown over the years that CBT is about 60 percent effective in treating anxiety­—but that still leaves about 40 percent of kids that don’t get better, “kind of suggesting that some kids need a little bit more,” said Silk, who is also a licensed clinical child psychologist.

So to augment the traditional course of CBT, they developed SmartCAT.

In addition to working to address the needs of the 40 percent of children who don’t improve, SmartCAT’s aims include mitigating two other factors that make standard CBT for anxiety challenging for some, Silk said. These factors are the typical need for 12-16 weeks of therapy, which can be tricky for busy families; and the lack of available, trained therapists in the community, which can lead to long wait lists and over-booked or unavailable clinicians.

Silk and Bambang Parmanto, professor and chair of Health Information Management in the School of Health and Rehabilitation Sciences, wanted to address these challenges while at the same time democratizing access to CBT.

“Our thinking was if we get kids practicing these skills that they’re learning in treatment on their phones every day, eventually even doing the exposures at home using the app, they could get better faster and more fully,” and shorten wait lists for therapists in the community, Silk said.

Earlier this year, Silk and a team published a paper showing that kids with anxiety who were successfully treated with CBT between ages 9 and 14 were less likely to have symptoms of depression—and fewer of them—years later.

Based on these findings, the app was designed for kids in late elementary to early high school, though that range could be expanded in the future, Silk said.

They did an open clinical trial in the University. Children and teens with anxiety received half the number of standard CBT sessions typically offered—eight compared to 16—but also used the SmartCAT app on their phones to practice skills on their own at home. The results were encouraging: 69% of kids no longer met criteria for an anxiety disorder at the end of treatment—a better outcome than the clinical standard of 60%, even with half as many sessions. The study was published in Behavior Therapy.

Why it matters

As social and academic pressures build throughout life, the things people struggle with also become more significant. “We really want to give kids the skills to master coping with their anxiety before those things become so challenging,” Silk said, especially in the current global political and environmental climate, which is contributing to rising rates of anxiety worldwide.

One feature of the app, developed by Parmanto and doctoral student Gede Pramana, is that it can be programmed to launch in a certain place with GPS tracking. So, if a child has anxiety around school shootings, for example, SmartCAT can launch one of its four skill-building games or the coaching module to help them through the school day as needed, while being quieter at home.

Other apps out there are designed to help kids manage their anxiety. But SmartCAT is “enhanced, evidence-based therapy,” said Parmanto. “It’s telemedicine, actually. A way of delivering care over a distance.” A clinician portal allows the doctor to engage, send secure messaging and monitor their patient’s progress.

“That’s why the results are better,” said Parmanto. “It’s a therapist in your pocket, enforcing what you do in a clinic, every day at home. A smartphone is with you all the time. If I want to know how anxious you are, it’s much more accurate if I asses it right there and then, in the moment it’s happening, than if you wait a few days for your appointment to tell me about it. Mobile health technology lets us assess patient condition and deliver therapy in the same moment.”

What’s happening now

Silk and the team were encouraged by SmartCAT’s success during the research period, but, she said, “what I really wanted to know was, can this work in the real world?”

One critical element? Reaching more kids. “Even though anxiety affects about one in six kids, fewer than 20% of anxious kids ever get any kind of treatment,” Silk said.

Pediatrics offices and schools seemed a good place to start, and convenient for families, the researchers decided.

Right now, they’re making SmartCAT available on Apple—it was developed for Android. With help from the Innovation Institute, they’re in the process of licensing the app to a company that will be able to provide long-term tech support, making it widely available to the public.

“I’ve had colleagues reaching out to me asking when they can download it for their kids,” said Parmanto. But before that can happen, there’s a bit more research to be done.

This fall, supported by a Pitt Seed grant as well as outside funding, they’re rolling out the app in selected pediatrics offices around Pittsburgh.

At the same time, another grant through Pitt’s social science research initiative is helping the team collaborate across units within the University. The psychology department, School of Medicine and School of Social Work are teaming up to train master of social work students who want to specialize in child mental health on using the abbreviated CBT protocol with SmartCAT, and implementing the intervention in a local Pittsburgh middle school.

Larger randomized trials in the community are on the horizon. But eventually, Silk hopes to scale the project up nationally. She sees the potential for better, stronger, longer-lasting outcomes for kids struggling with anxiety that could have lasting positive impacts much further down the line in the life and mental health journey of so many individuals.