Engaging Children and Young People in Digital Mental Health Interventions: Systematic Review of Modes of Delivery, Facilitators, and Barriers

Background There is a high prevalence of children and young people (CYP) experiencing mental health (MH) problems. Owing to accessibility, affordability, and scalability, an increasing number of digital health interventions (DHIs) have been developed and incorporated into MH treatment. Studies have shown the potential of DHIs to improve MH outcomes. However, the modes of delivery used to engage CYP in digital MH interventions may differ, with implications for the extent to which findings pertain to the level of engagement with the DHI. Knowledge of the various modalities could aid in the development of interventions that are acceptable and feasible. Objective This review aimed to (1) identify modes of delivery used in CYP digital MH interventions, (2) explore influencing factors to usage and implementation, and (3) investigate ways in which the interventions have been evaluated and whether CYP engage in DHIs. Methods A literature search was performed in the Cochrane Library, Excerpta Medica dataBASE (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and PsycINFO databases using 3 key concepts “child and adolescent mental health,” “digital intervention,” and “engagement.” Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least two reviewers. The selected articles were assessed for quality using the mixed methods appraisal tool, and data were extracted to address the review aims. Data aggregation and synthesis were conducted and presented as descriptive numerical summaries and a narrative synthesis, respectively. Results This study identified 6 modes of delivery from 83 articles and 71 interventions for engaging CYP: (1) websites, (2) games and computer-assisted programs, (3) apps, (4) robots and digital devices, (5) virtual reality, and (6) mobile text messaging. Overall, 2 themes emerged highlighting intervention-specific and person-specific barriers and facilitators to CYP’s engagement. These themes encompassed factors such as suitability, usability, and acceptability of the DHIs and motivation, capability, and opportunity for the CYP using DHIs. The literature highlighted that CYP prefer DHIs with features such as videos, limited text, ability to personalize, ability to connect with others, and options to receive text message reminders. The findings of this review suggest a high average retention rate of 79% in studies involving various DHIs. Conclusions The development of DHIs is increasing and may be of interest to CYP, particularly in the area of MH treatment. With continuous technological advancements, it is important to know which modalities may increase engagement and help CYP who are facing MH problems. This review identified the existing modalities and highlighted the influencing factors from the perspective of CYP. This knowledge provides information that can be used to design and evaluate new interventions and offers important theoretical insights into how and why CYP engage in DHIs.


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Breathe is an internet-based CBT treatment program. The program includes online (CBT treatment modules) and Internet (e-mail support) based features as well as telephone support provided by a trained health care professional ('Anxiety Expert').
Website: videos, homework Anxiety disorders 1* 2 Bounce Back Now (BBN) includes 4 modules to manage PTSD, depressions, ciagrette use and alcohol use; each module has screening questions for relevant symptoms (those without relevant symptoms could complete or skip a given module); modules were developed using evidence-based treatments for the respective conditions. Treatment approach is done through pychoeducation, exposure, coping, behavioural activiation, motivational-enhancement and CBT.
Website: text, graphics, anmisations, videos, and quizzes Depression, PTSD, substance use 1, 4* 3 BRAVE for Children-ONLINE is adapted from a clinic-based, CBT anxiety treatment program (the BRAVE Program) and based on theoretical and empirical research relating to the psychosocial determinants of child anxiety.
Website: quizzes, pop-ups, homework tasks, automated reminders, profile set up, animations, sound clips, and interactive quizzes, weekly emails, games.
anxiety 1 4 Mood Mechanic Course, an internet-delivered cognitive behavioural therapy for young adults with anxiety and depression which consisted of four lessons delivered over 5 weeks.
Website: phone calls, emals, text messages anxiety and depression 1 5 WebTIPS: tailored, innovative, web-based preoperative preparation program for children undergoing surgery and their parents. The children's website is tailored based upon children's trait anxiety and type of surgery and includes information provision, modeling, and coping skills through CBT.
Website: Games, video, audio, animations anxiety 1 1-Provide trageted MH information to CYP based on health status or demographic; 2-Provide MH information to the general public; 3-Facilitate peer support network; 4-Facilitate personal health tracking 6 BRAVE for Teenagers-ONLINE: Standard CBT anxiety management strategies were used, including psychoeducation, relaxation training, recognition of the physiological symptoms of anxiety, cognitive strategies of coping self-talk and cognitive restructuring, graded exposure, problem solving, and self-reinforcement. The content, length, and number of session activities in the Internet program replicate those of the clinic-based session. Information is presented through interactive exercises and is followed by quizzes that check for correct understanding and provide personalized corrective or positive feedback through pop-up messages.
Website: Eye-catching graphics, sounds, games, and quizzes meet criteria for a principal diagnosis of separation anxiety disorder, generalized anxiety disorder, social phobia, or specific phobia. ICBT (internet-based cognitive behavioral therapy) was adapted for adolescents and involves 6-9 treatment modules.
Website: combined with additional telephone calls or face-to-face sessions if required.
Anxiety disorders 1 10 PRIME: Personalized real-time CBT intervention for motivational enhancement, a supportive online environment where persons select and document progress on small, self-determined goals in the domains of health/wellness, social relationships, creativity, and productivity.
Website: automated reminders, social networking recent-onset schizophrenia spectrum disorders (SSDs). . Each trial consisted of either a 3x3 or a 4x4 picture array containing unpleasant background images (e.g. house on fire, person in hospital) and between one and three positive targets which are either 'good' targets (e.g., happy children; cute animals) or 'calm' targets (e.g., a vase; a book), which are less positive than 'good' targets but still positive to focus on given that not every situation will contain an explicitly pleasant stimulus to focus on.

Games
Anxiety disorders (separation anxiety disorder, generalized anxiety disorder, social phobia, specific phobia) 1 37 Brain-computer interface (BCI) includes training games using electroencephalogram (EEG). The BCI can quantify one's attention level as measured by EEG waves, thereby allowing users to employ their attention to play these games directly.

Games
Attention deficit hyperactivity disorder Training 38 Camp Cope-A-Lot (CCAL): interactive computer-assisted treatment program derived from the Coping Cat cognitive behavioral treatment approach for anxiety in youth. Throughout the program, participants followed along and participated with Charlie, a "camper" at CCAL, to learn coping strategies for anxiety and to overcome fears through exposures.
Games anxiety symptoms 1 39 Captain's Log -Computer-assisted cognitive remediation (CACR) consists of five modules; the software consists of 35 multi-level "brain-training" exercises designed to develop and remediate attention, concentration, memory, eye-hand coordination, basic numeric concepts, problemsolving/reasoning skills, self-esteem and self-control.

Games
Psychosis or at High Risk of Psychosis Development 40 OnTrack: computer-based role-playing game for young people with psychosis. The Game allows players to explore an imaginary world. computer game that provided a psychometric assessment of symptoms, supports a CBT intervention and coaches mindfulness and self-regulation skills for young people aged 9 -12 with anxiety and low mood.
Games anxiety and /or depression 1 42 RoboMemo: a CBT based programme consisting of performing working memory tasks implemented in a computer program. The program included visuospatial tasks grid as well as verbal tasks.
Games ADHD (diagnosis) 1 43 The cognitive training games are three colorful and engaging games with interesting sound effects. These games were designed with principles to train fixation, speed and accuracy of eye movements and control of visuospatial attention.
Games diagnosis of ASD Skills Training (fixation, speed and accuracy of eye movements and control of visuospatial attention) 44 The Emotion Trainer is a multimedia computer program. On each page of the program a digital photograph of a face, a scene or an object is shown, with a short text question and either two or four response buttons. 1 49 SPARX-R is a CBT-based self-help intervention framed as a prevention program targeting feelings of anger, stress and feeling low mood.
Computer Game (Offline) targeting feelings of anger, stress and feeling low rather than depression 1, 2 50 Braingame Brian: a computerized, home-based executive functioning training, embedded in a game world and is named after its main character "Brian". Brian is a young inventor who, throughout the game, helps and befriends the game-worlds inhabitants by creating increasingly elaborate inventions (e.g., a delivery-rocket for the grocery-store owner). Training tasks include: 1: working memory, 2 cognitive flexibility, 3 inhibition task.