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The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years).
This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user’s experience of the digital intervention.
A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality.
Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs)
Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (
The prevalence of chronic health conditions in childhood is increasing [
Behavioral interventions can support the treatment and management of chronic health conditions and can be effective in improving symptom management, reducing physical disability, and improving mental health [
Digital interventions can deliver behavior change interventions using mobile phones, smartphones, portable computers, desktop computers, the internet, wearable technology, and television [
Despite the increasing availability of digital interventions and a growing body of evidence for adults and adolescents, there has been inadequate attention to designing and delivering these interventions to children. Children have different developmental characteristics and needs, and the developmental stage of children should be considered when designing interventions [
Therefore, this review aimed to explore digital interventions for the management of chronic health conditions in children aged between 5 and 12 years.
Behavior change interventions are often complex [
This systematic review aimed to investigate digital interventions for the management of chronic health conditions in children aged between 5 and 12 years. We used an inclusive definition of chronic health conditions that included both physical and mental health. Conceptually, behavioral interventions for physical and mental health conditions are the same; they are designed to change the child’s behavior to improve the clinical outcome. Furthermore, there is a strong overlap between physical and mental conditions; comorbidity of physical and mental health conditions is common [
The review was prospectively registered in the Prospective Register of Systematic Reviews (PROSPERO) database.
We carried out a systematic search of relevant databases: Excerpta Medica Database (EMBASE), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Cochrane Library (January 2019). The search strategy included keywords and Medical Subject Headings (MeSH) for (1) children aged between 5 and 12 years, (2) behavior change, (3) randomized controlled trials (RCTs), (4) digital interventions, and (5) chronic health conditions (we used a mixture of generic terms, ie, “Chronic disease,” and also search-specific terms, informed by the most common chronic illness in childhood;
To be included in this review, studies had to fulfill the following criteria:
Include children aged between 5 and 12 years (this review aimed to examine digital interventions for children in the developmental stages of middle childhood).
Include children with a chronic health condition, excluding those with developmental delays.
Investigate a digital intervention to promote behavior change. Digital interventions included those delivered via internet (static or interactive websites, automated emails, or web-based apps), personal computers (PCs; eg, PC videogames), social media, mobile phones (automated phone calls or short text messages), or smartphones (mobile websites or smartphone apps). These may be stand-alone interventions or guided (eg, therapist supported).
Compare the digital intervention with any comparator.
Have an RCT study design (RCTs are considered the gold standard for judging the benefits of treatments [
Published in peer-reviewed journals and available in English.
Published between 2014 and January 2019. We chose a 5-year time frame because of the rapid pace of digital interventions [
Titles and abstracts (stage 1) and full-text papers (stage 2) were independently double screened against the inclusion and exclusion criteria using the data management platform Rayyan (stage 1) and Covidence (stage 2). AB screened all papers, and CL, LS, and EB were responsible for the independent second screening. Reasons for exclusion were recorded at stage 2. Discrepancies at both stages were discussed and resolved in meetings by the reviewers. Papers were tracked using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [
For data extraction, papers were reviewed independently by 2 researchers and conflicts were resolved in regular meetings (AB reviewed all papers, and CL, LS, and EB were responsible for an independent second review). Two researchers independently coded BCTs (EA and AB, a health psychologist and health psychology trainee, respectively). We extracted information that allowed us to answer the 2 primary research questions, as described in
Due to the clinical and methodological heterogeneity, we synthesized data using narrative synthesis [
Data extraction.
Data extraction category | Details extracted |
Population |
Age: the age range of the population, at the time of entry into the study. Ages were then grouped by UK school 5-7 years, corresponding to key stage 1. 8-11 years, corresponding to key stage 2. 12 years, corresponding to key stage 3. Chronic health condition: the chronic health condition that the intervention was designed to target. |
Overview of intervention |
Overview of aims: the overview of the aims of the RCTa. Overview of intervention: an overview of the digital component of the intervention and, if applicable, other key components. Overview of comparator: an overview of the comparator arm or arms. |
Aim 1: effectiveness |
Overview of Interventions were deemed Interventions were deemed Interventions were deemed Interventions were deemed Interventions were put in the category The direction and size of the effect [ Summary of the effect of the intervention compared with the control. Statistic comparing the change in the intervention group and control group from baseline to final follow-up. Where sufficient information was available comprising either SDs and numbers of participants, or SEs, we calculated the net mean difference (difference in mean changes), with 95% CI and If available, we reported the adjusted mean difference (adjusted for baseline measures) as this is the accepted best method. Outcome measure: all behavioral outcomes were extracted, as exploring the effect of the intervention on behavior change was the primary aim of this review. The primary outcome was also extracted as this is the main determinant of whether the study is considered a the behavior and or primary outcome how this was measured the final time point. Adverse events: health interventions carry some risk of harm. Systematic reviews should minimize bias toward favoring an intervention by assessing adverse effects alongside beneficial effects [ |
Aim 2: characteristics of promising interventions |
The following data were extracted from very promising, quite promising, and possibly promising interventions: Recipients: whether the intervention was delivered directly to the child, via a parent-proxy or both. Intervention techniques: intervention techniques refer to what is being delivered, the content or We coded whether each BCT identified was delivered to the parent or the child and whether it featured in the digital or human component. Digital mode of delivery: intervention mode of delivery refers to how the content is delivered. We categorized mode of delivery, based on elements of the mode of delivery Taxonomy [ Theoretical basis: whether a named theory of behavior or behavior change was explicitly mentioned in the Abstract, Introduction, or Methods section [ Modality: the intervention modality, coded as either a first, second, or third wave intervention. |
Aim 3: The users’ experience of the digital intervention |
Qualitative analysis: two researchers independently reviewed all eligible papers and identified those that included qualitative data about the users’ experience of the digital intervention. Qualitative data were extracted, compared, and summarized into themes. |
aRCT: randomized controlled trial.
As all studies in this review were RCTs, the Cochrane risk of bias tool for randomized trials (RoB 2.0) [
After deduplication, 2643 papers were identified from the database searches, of which 18 papers were identified as eligible for inclusion. Two of these papers reported on the same intervention; therefore, we identified 17 digital interventions for the management of chronic health conditions in children aged between 5 and 12 years.
PRISMA flow diagram. RCT: randomized controlled trial.
The digital interventions targeted a range of chronic health conditions, including overweight or obesity (n=7), anxiety and preoperative anxiety (n=3), cerebral palsy (n=3), attention-deficit/hyperactivity disorder (ADHD; n=1), type 1 diabetes (n=1), asthma (n=1), and social-emotional problems (n=1). All the interventions included children of key stage 2 age (8-11 years), 13 included children of key stage 3 age (12 years), and 9 included children of key stage 1 age (5-7 years).
No interventions were identified as
A total of 5 interventions were identified as
Data on population, interventions, and effectiveness of behavior change outcomes and primary outcomes, grouped by intervention promise.
Categories and reference | Condition; age | Overview of intervention/recipients | Recipients | Behavior change outcome | Primary outcome (if different) | |
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Ahmad et al (2018) [ |
Overweight or obesity; 8-11 years | Digital component: 2 training units delivered weekly via Facebook. Weekly 1-hour sessions using a parents’ WhatsApp group that lasted for 12 weeks. In the WhatsApp group, the researchers posted key information and skills, responded to parent queries, and provided feedback on the adiposity progress of the children. Parents were encouraged to interact with the group WhatsApp group; additional component: 2 half-day face-to-face training sessions | Digital component: parent only; face-to-face component: parent and child | Healthy lifestyle behaviors, children’s eating, physical activity, and screen time: effectiveness data not reported | BMI Z-score: the intervention group had a reduced BMI Z-score compared with the control. Net mean differencea=−0.14 (95% CI −0.278 to −0.003; |
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Jolstedt et al (2018) [ |
Anxiety; 8-12 years | Digital component: ICBTb. A web-based program with 12 modules delivered over 12 weeks, consisting of texts, films, illustrations, and exercises and focused mainly on exposure therapy. Limited weekly asynchronous support from a clinician to encourage families to engage in the program. Twelve parent-directed modules, covering parental behaviors, which can maintain anxiety and how to best support their child. Parents helped children with the child-directed modules | Digital component: parent and child; face-to-face component: parent and child | None reported | Anxiety (CSR)c: Participants allocated to ICBT showed improvements on the CSR compared with the control. Net mean difference=0.79 (95% CI 0.42-1.16; |
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Staiano et al (2018) [ |
Overweight or obesity; 10-12 years | Digital component: participants were provided a Kinect and Xbox 360 gaming console, 4 exergames, and a Fitbit Zip to wear during the 24-week period. Steps per day were wirelessly uploaded and reviewed by the fitness coach; additional component: telehealth, consisting of the child and parent meeting with a fitness coach over video chat, on a weekly basis for the first 6 weeks and biweekly thereafter | Digital component: child only; face-to-face component: parent and child | Physical activity: the intervention showed an increase in MVPAd compared with the control group; estimated mean difference 11.4 min of MVPA per day (95% CI 2.25-20.55); Dietary habits: there was no evidence of effect | BMI Z-score: there was no clear evidence of effect |
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Trost et al (2018) [ |
Overweight or obesity; 8-12 years | Digital component: participants were provided a game console and motion capture device (Xbox and Kinect; Microsoft Corporation) and 2 active sports games. No explicit advice or goals were given to any study participant regarding the use of their active gaming tool; additional component: a comprehensive family-based pediatric weight management program | Digital component: child only; face-to-face component: parent and child | Physical activity: the intervention group exhibited a greater increase in MVPA compared with the control group. Net mean difference=8 min of MVPA per day (SE 3.8; 95% CI 0.5-15.4; |
The primary outcome was physical activity (see the behavioral outcomes column) |
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Vigerland et al (2016) [ |
Anxiety; 8-12 years | Digital component: a treatment platform with 11 modules, including reading material, films, animations, illustrations, and exercises. A combined parent-child intervention. Seven parent-directed modules containing information and instructions on how to help their child. Four child-directed modules. Participants had web-based contact with an assigned psychologist or CBT therapist through written messages and written feedback. Three scheduled telephone calls plus additional telephone calls if needed (to increase motivation or problem solve) | Digital component: parent and child; face-to-face component: parent and child | None reported | Anxiety (CSR): the intervention group had a larger improvement on the CSR. Net mean difference=−1.16 (95% CI −0.77 to −1.55) |
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Bul et al (2016) [ |
ADHD; 8-12 years | Digital component: a serious web-based adventure game (Plan-It Commander) developed by health care professionals, researchers, and game experts in collaboration with parents and children with ADHD. A web-based mission-guided game in which principles of behavior therapy and game-based learning were combined. The missions addressed specific skills addressing time management, planning and organizing, and prosocial behavior. Players could access a closed social community ( |
Digital component: child only; face-to-face component: N/Ae | Time management: the intervention arm showed greater improvements in parent-reported time management skills compared with the control arm. Estimated net mean difference of parent-reported time management=5.98 (95% CI 1.32-10.64) and teacher time management=5.46 (95% CI 1.71-9.20); planning and organizing skills, social skills: no clear evidence of effect | The 3 primary outcomes were: parent-reported time management, parent-reported planning and organization, and parent-reported social skills (see the behavioral outcomes column) |
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Hsieh et al (2018) [ |
Cerebral palsy; 5-10 years | Digital component: a PCf gaming platform. The participants stood in front of the platform and viewed a monitor that displayed 1 of a series of simulated tasks, such as hitting ground rats. The gaming platform handle was loaded, 0.5 to 2.5 lb. This PC gaming platform provided trunk movements in 3 directions: horizontal, vertical, and multidirectional trunk movements | Digital component: child only; face-to-face component: child only | None reported | Measures of postural balance: there was clear evidence of effect of the intervention for 2 of the 7 measures |
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Wantanakorn et al (2018) [ |
Preoperative anxiety; 5-12 years | Digital component: |
Digital component: child only; face-to-face component: N/A | N/A | Preoperative anxiety: anxiety was lower in the intervention group versus the control group. Estimated difference means=−7.71 (95% CI −14.27 to −1.15) |
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Armstrong et al (2017) [ |
Overweight or obesity; 5-12 years | Digital component: daily mobile text messages, based on motivational interviewing, for 12 weeks. Initial texts encouraged parents to set a health behavior goal. In a reply text, the investigators reinforced the most evidence-based goals for BMI reduction (sugar-sweetened beverage reduction, increased physical activity, eating meals at home, and increased vegetable consumption). Subsequent daily texts prompted parents to self-monitor adherence to the goal. Each week for 12 weeks, parents can choose a new goal or continue working on the present goal; additional component: standard care, including monthly lifestyle counseling visits by a physician and dietician | Digital component: parent only; face-to-face component: parent only | Child nutrition habits, activity habits and screen time: no clear evidence of effect of intervention | BMI Z-score: no clear evidence of effect of intervention |
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Christison et al (2016) [ |
Overweight or obesity; 8-12 years | Digital component: The Exergaming for Health Program is a community-based, multifaceted pediatric weight management program including 1 hour of weekly group exergaming; additional component: classroom curriculum | Digital component: child only; face-to-face component: parent and child | Activity levels, sedentary screen time, and diet: no clear evidence of effect of intervention | BMI Z-score: no clear evidence of effect of intervention |
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Sanchez et al (2017) [ |
Social-emotional problems; 7-11 years | Digital component: a single-player story-based digital game that requires children to apply specific social-emotional skills to solve social problems encountered in the game. For example, approaching an individual that appears easy to talk to, joining a group at a game in progress, and approaching small groups that appear less easy to talk to. Within each scenario, the player had to make behavioral choices and individualized feedback to choices was given | Digital component: child only; face-to-face component: N/A | Bullying perpetration: no clear evidence of effect of intervention | No primary outcome specified |
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Burckhardt et al (2018) [ |
Type 1 diabetes; 8-12 years | Digital component: the Dexcom G5Ò Mobile continuous glucose monitoring system transmitted glucose levels via Bluetooth to a mobile device that generated alerts. This information could be shared via the |
Digital component: child only; face-to-face component: N/A | Pilot study (n=14) | No primary outcome specified |
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Fiks et al (2015) [ |
Asthma; 6-12 years | Digital component: the features of MyAsthma include identification of parents’ concerns and goals for asthma treatment; monthly tracking of symptoms, medication side effects, and progress toward goals; educational content; and access to the child’s asthma care plan. Parents were encouraged with email reminders to complete monthly portal surveys with input from their affected child. In response to these surveys, families and clinicians received guideline-based decision support that directed them to speak to one another if asthma was not well controlled or if there were side effects, or to continue current therapy | Digital component: parent only; face-to-face component: parent only | Only acceptability or feasibility data | Only acceptability or feasibility data |
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Hamilton-Shield et al (2014) [ |
Overweight or obesity; 5-11 years | Digital component: Mandolean teaches patients how to eat and recognize satiety. The patient puts a measured portion of food determined by a therapist on the Mandolean (scales and computer), which records and displays, in real-time graphics, the removal of food from the plate as the patient eats. This is compared with a preset eating line and deviation from the training line by eating too quickly or slowly elicits a spoken request from Mandolean to slow down or eat faster. The patient rates their level of satiety, which appears as a dot on screen yielding a |
Digital component: child only; face-to-face component: parent and child | None of the pilot trial’s objectives were met; thus there were no full trial effectiveness results | BMI Z-score: none of the pilot trial’s objectives were met; thus there were no full trial results |
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Kassee et al (2017) [ |
Cerebral palsy; 7-12 years | Digital component: a Nintendo Wii U system, 1 Wii MotionPlus remote controller, 1 Wii Nunchuck, and the Wii Sports Resort game to be played at home. Games were designed to promote higher upper-limb activity. Participants were instructed to play games using their affected hand for at least 40 min each day, 5 days a week for 6 weeks (30 days); additional component: parents supervised and recorded sessions and were asked to encourage the child to use their spastic hand as much as possible | Digital component: child only; face-to-face component: parent and child | Pilot study (n=6) | Pilot study (n=6) |
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Preston et al (2016) [ |
Cerebral palsy; 5-12 years | Digital component: computer-assisted arm rehabilitation gaming used at the child’s home. Parents were asked to encourage their children to use the gaming technology for 30 min a day; additional component: a visit at week 3 to offer encouragement and to check the gaming technology system. Usual follow-up treatment | Digital component: child only; face-to-face component: parent and child | None reported | Pilot study (n=15) |
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Price et al (2015) [ |
Overweight or obesity; 6-12 years | Digital component: text messages to parents to reinforce telephone health behavior coaching. Text messages to promote behavioral self-monitoring and skills training, focused on behaviors, including limiting fast food and eating fruits and vegetables in place of high-calorie snacks. At the time of a well child care visit, digital alerts were sent to pediatricians designed to identify children with a BMI ≥95th percentile. These contained information on how to monitor and support the child; additional component: Well child visit | Digital component: parent only; face-to-face component: parent only | Only acceptability or feasibility data | Only acceptability or feasibility data |
aNet mean difference indicates the difference in mean change between the intervention and the control arms of the study.
bICBT: internet-delivered cognitive behavioral therapy.
cCSR: clinician severity rating.
dMVPA: moderate-to-vigorous physical activity.
eN/A: not applicable.
fPC: personal computer.
In all, 3 interventions were identified as
Three interventions showed no promise; 2 of these were targeting overweight and obesity, 1 was the exergaming plus classroom curriculum, and the other was motivational interviewing delivered via one-way text messaging [
Six interventions were pilot studies, and they only reported acceptability or feasibility data [
Adverse events for each study are reported in
Summary of adverse events.
References | Details of adverse events |
Ahmad et al (2018) [ |
“No adverse events or unintended adverse consequences of the intervention were reported by the participants.” |
Armstrong et al (2017) [ |
“We observed no adverse events associated with participation in the text message intervention.” |
Bul et al (2016) [ |
“There were 10 adverse events that could be related to the intervention... All adverse events were of mild (n=5) or moderate (n |
Burckhardt et al (2018) [ |
Did not capture adverse events. |
Christison et al (2016) [ |
Did not capture adverse events. |
Fiks et al (2015) [ |
Did not capture adverse events. |
Hamilton-Shield et al (2014) [ |
“There were no adverse events regarded as serious, unexpected or suspected to be related to the study treatment” |
Hsieh et al (2018) [ |
Methods: “no adverse effects were expected in participants in the intervention group.” No further details of adverse effects were reported. |
Jolstedt et al (2018) [ |
“No severe adverse events were reported in either group... The number of adverse events was similar between the groups.” Total reported adverse events: ICBTa 17 (26%), ICDP (active control) 16 (25%). |
Kassee et al (2017) [ |
Did not capture adverse events. |
Preston et al (2016) [ |
“No adverse events were reported.” |
Price et al (2015) [ |
Did not capture adverse events. |
Sanchez et al (2017) [ |
Did not capture adverse events. |
Staiano et al (2018) [ |
“Among those randomized to the intervention group, two children reported an injury during gameplay (bruise to the ankle or wrist).” “Two adverse events (bruising) were reported in the GameSquad trial, which is similar to prior exergaming studies reporting minor bruises, hand lacerations and back pain ...” |
Trost et al (2018) [ |
Did not capture adverse events. |
Vigerland et al (2016) [ |
Did not capture adverse events. |
Wantanakorn et al (2018) [ |
Did not capture adverse events. |
aICBT: internet-delivered cognitive behavioral therapy.
We considered the 8 interventions that were classified as promising, quite promising, and possibly promising to represent
A total of 7 of the 8 interventions had a digital component for the child, and all the interventions involved the child in some capacity (either digital or human component). In all, 5 of the 8 interventions involved the parent in some capacity (either digital or human component).
All the promising interventions used more than one BCT. Digital components for the child typically included techniques coded into the following BCT categories:
The most promising interventions were for overweight or obesity (3 studies) and anxiety (2 studies). All 3 of the promising overweight or obesity interventions included a face-to-face component for both the parent and the child. Two interventions included a digital component for the child, both using the BCT repetition and substitution. Only 1 intervention had a digital component for the parent.
Both promising anxiety interventions included digital and face-face elements, all of which involved both the child and the parent. Both interventions used the following BCTs in the digital component: goals and planning (child and parent components), shaping knowledge (child and parent components), feedback and monitoring (parent component), and associations (child component).
We acknowledge that there may have been more BCTs included in the intervention; however, we were unable to code these as they were not explicitly reported in the paper. Furthermore, it was often unclear as to whether the BCT was delivered to the parent or the child and by what means it was planned to take effect. In some cases, we believe that the BCTs were directed at the parent, with the parent then eliciting behavior change in the child. However, none of the papers addressed this level of complexity; they did not describe this mechanism of change nor did they include a parent behavior change outcome measure.
Definitions of behavior change techniques.
BCTa categoriesb | Definitions |
Goals and planning | Includes setting and reviewing goals defined in terms of the behavior (eg, physical activity) or the outcome (eg, weight loss); problem-solving to overcome barriers and or increase facilitators; and detailed action planning of the behavior, considering the context, frequency, duration, and intensity of the behavior |
Feedback and monitoring | Includes observing or recording the behavior or the outcome either by the recipient (self-monitoring) or by others; feedback on the performance of the behavior or the outcome |
Shaping knowledge | Includes advising how to perform the behavior, the factors that reliably predict performance of the behavior, alternatives to unhealthy behaviors, and how to carry out behavioral experiments |
Repetition and substitution | Includes practicing the behavior in a context or at a time when the performance may not be necessary to increase habit and skill; setting easy-to-perform tasks, making them increasingly difficult, but achievable, until the behavior is performed |
Reward and threat | Includes using material (eg, money and vouchers) or social (eg, praise) incentives and rewards for the behavior or outcome; informing that future punishment or removal of reward will be a consequence of performance of an unwanted behavior |
Social support | Includes advising, arranging, or providing social support (eg, from friends, relatives, colleagues, “buddies,” or staff) for practical and or emotional reasons |
Natural consequences | Includes providing information (eg, written, verbal, visual) about the health, social, emotional, or environmental consequences of performing the behavior; using methods to emphasize the consequences |
Associations | Includes introducing environmental or social stimulus to prompt or cue behavior; reducing situations in which unwanted behavior can be rewarded; systematic confrontation with a feared stimulus to reduce the response to a later encounter; and presenting a neutral stimulus jointly with a stimulus that already elicits the behavior repeatedly until the neutral stimulus elicits that behavior |
aBCT: behavioral change techniques.
bThe study by Michie et al [
Characteristics of promising interventions.
Characteristics | Child recipient–digital component (n=7), n (%) | Child recipient–human component (n=6), n (%) | Parent or caregiver–digital component (n=3), n (%) | Parent or caregiver–human component (n=5), n (%) | |||||
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Tailored | 1 (14) | N/Aa | 1 (33) | N/A | ||||
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Guided | 5 (71)b | N/A | 3 (100)b | N/A | ||||
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Gaming features | 5 (71)b | N/A | 2 (67)b | N/A | ||||
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Goals and planning | 3 (43) | 3 (50)b | 3 (100)b | 4 (8)b | ||||
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Feedback and monitoring | 4 (57)b | 4 (67)b | 0 (0) | 4 (80)b | ||||
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Social support | 2 (29) | 3 (5)b | 3 (100)b | 4 (80)b | ||||
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Shaping knowledge | 4 (57)b | 3 (50)b | 1 (33) | 3 (60)b | ||||
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Natural consequences | 0 (0) | 0 (0) | 2 (67)b | 1 (20) | ||||
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Comparison of behavior | 2 (29) | 2 (33) | 1 (33) | 1 (20) | ||||
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Associations | 2 (29) | 1 (17) | 1 (33) | 1 (20) | ||||
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Repetition and substitution | 5 (71)b | 0 (0) | 0 (0) | 0 (0) | ||||
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Comparison of outcomes | 0 (0) | 1 (17) | 1 (33) | 1 (20) | ||||
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Reward and threat | 6 (86)b | 2 (33) | 1 (33) | 1 (20) | ||||
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Regulation | 1 (14) | 0 (0) | 0 (0) | 0 (0) | ||||
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Antecedents | 1 (14) | 2 (33) | 1 (33) | 2 (40) | ||||
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Identity | 0 (0) | 0 (0) | 1 (33) | 1 (20) | ||||
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Scheduled consequences | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||||
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Self-belief | 0 (0) | 1 (17) | 1 (33) | 2 (40) | ||||
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Covert learning | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
aN/A: not applicable.
b≥50% of interventions using the characteristic.
A total of 5 of the 7 interventions with child digital components used gaming features. All the parent digital components and 5 of the child digital components were guided. In all, 3 digital interventions involving parents and 1 digital intervention for the child were tailored.
Half of these papers reported the use of theory in the intervention: social cognitive (n=2) and CBT (n=2).
A total of 6 of the 8 interventions were first wave (purely behavioral) interventions, and 2 were second wave (cognitive-behavioral) interventions. There were no third wave interventions.
Only 3 of the studies included qualitative data on users’ experiences and views of the intervention [
Parents talked about the interventions improving their knowledge (“made me more aware”) and shaping their behavior, which in turn led to the child’s behavior change (“it does make me stop him and sit him down and make him eat the breakfast”). Some commented on the problems of parent-led interventions and how a health professional, who is external to the parent-child relationship, is important to encourage the child’s behavior change (“I think some kids will listen to their doctor better than their parents”).
Digital interventions were seen to facilitate
Parents commented on the technologies being quick, easy, and possible to integrate into everyday life. However, others commented on practical challenges such as the cost, lack of familiarity, and difficultly to use. Users commented on the fixed nature of the technology, which meant that it was not personalized to their individual preferences or needs (“but I really want to focus on these”) and did not deliver content with ongoing relevance that would maintain engagement over time (“I think enthusiasm’s gone off”).
Children commented on some of the interventions being enjoyable (“I like the electronic stuff”). However, in other cases, the material was not understood by the child (“It’s really confusing
To the best of our knowledge, this is the first review to identify effective digital interventions for younger children, report the characteristics of promising interventions, and describe the user’s experience of digital interventions. Of the 17 eligible interventions, we only identified 5 that had a beneficial effect and had a low risk of bias; 3 targeted overweight or obesity, using exergaming or social media with additional human support, and 2 targeted anxiety, using web-based CBT with therapist support.
Characteristics of promising digital interventions included gaming features in the child digital component and having additional therapist support (guided digital interventions). Digital components for the child typically used the BCTs [
Only 3 papers used qualitative methods to explore the users’ experience of digital intervention. These studies reported the affordances of digital interventions, including ease of use, integration into daily life, and the ability to enhance communication with a health professional. However, a lack of personalization, technical problems, and cost issues posed challenges to families. The qualitative data indicated how the content (eg, language and concepts) and design could be improved for younger users.
We included a range of chronic health conditions, which enabled us to review a larger number of interventions and identify patterns or commonalties of promising interventions. Spanning health conditions makes these findings relevant to a wide audience of researchers working in the field of digital interventions. We focused on RCTs because they have the strongest study design and are most likely to be adopted in clinical care [
Guidance was followed on how to report effectiveness in narrative reviews [
A limitation of this review is that we only included RCTs. Although observational studies and nonrandomized trials could have provided additional information on the characteristics and effectiveness of digital interventions for this population, we excluded these study designs as they have a greater potential for risk of bias [
This review identified promising exergaming and social media interventions for children with obesity or overweight and web-based CBT for children with anxiety. There is potential for these to be implemented in clinical practice with further surveillance, monitoring, and long-term follow-up [
This work highlights characteristics that may be beneficial when developing digital interventions for younger populations. The finding that purely behavioral interventions (first wave, not including cognitive components) are common in promising interventions is consistent with developmental theory; children tend to be limited to concrete thought [
Guidelines encourage standardized reporting of interventions to ensure transparency and reproducibility [
The low number of promising interventions demonstrates the need to better understand the perspective of those receiving interventions. Few studies have conducted qualitative research to explore the user’s experiences. Qualitative methods, such as the person-based approach [
Conceptualising and reporting interventions involving both the parent/caregiver and the child. BCT: behavior change techniques.
Of the 17 interventions, we only identified 5 with promise (those with a beneficial effect and low risk of bias). Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this under-researched younger population. Promising interventions were exergaming and social media for obesity or overweight and a web-based CBT platform for anxiety. We identified characteristics that could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (
Search Strategy.
Full data extraction table.
Summary of risk of bias assessment.
The users experience and views on the digital intervention; raw qualitative data and themes.
attention-deficit/hyperactivity disorder
behavior change technique
cognitive behavioral therapy
moderate-to-vigorous physical activity
National Institute for Health Research
personal computer
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
AB is funded by a National Institute for Health Research (NIHR), (NIHR Doctoral Research Fellowship, DRF-DRF-2017-10-169) for this research project. ML is funded by a National Institute for Health Research (NIHR), (NIHR Doctoral Research Fellowship, DRF-2016-09-021) for this research project. EC was funded by a National Institute for Health Research (NIHR), (NIHR Senior Research Fellowship, SRF-2013-06-013) for this research project. This publication presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
None declared.