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Internet-based cognitive behavioral therapy (iCBT) for children and adolescents is a persuasive system that combines 3 major components to therapy—therapeutic content, technological features, and interactions between the user and program—intended to reduce users’ anxiety symptoms. Several reviews report the effectiveness of iCBT; however, iCBT design and delivery components differ widely across programs, which raise important questions about how iCBT effects are produced and can be optimized.
The objective of this study was to review and synthesize the iCBT literature using a realist approach with a persuasive systems perspective to (1) document the design and delivery components of iCBT and (2) generate hypotheses as to how these components may explain changes in anxiety symptoms after completing iCBT.
A multi-strategy search identified published and gray literature on iCBT for child and adolescent anxiety up until June 2019. Documents that met our prespecified inclusion criteria were appraised for relevance and methodological rigor. Data extraction was guided by the persuasive systems design (PSD) model. The model describes 28 technological design features, organized into 4 categories that help users meet their health goals: primary task support, dialogue support, system credibility support, and social support. We generated initial hypotheses for how PSD (mechanisms) and program delivery (context of use) features were linked to symptom changes (outcomes) across iCBT programs using realist and meta-ethnographic techniques. These hypothesized context-mechanism-outcome configurations were refined during analysis using evidence from the literature to improve their explanatory value.
A total of 63 documents detailing 15 iCBT programs were included. A total of six iCBT programs were rated high for relevance, and most studies were of moderate-to-high methodological rigor. A total of 11 context-mechanism-outcome configurations (final hypotheses) were generated. Configurations primarily comprised PSD features from the primary task and dialogue support categories. Several key PSD features (eg, self-monitoring, simulation, social role, similarity, social learning, and rehearsal) were consistently reported in programs shown to reduce anxiety; many features were employed simultaneously, suggesting synergy when grouped. We also hypothesized the function of PSD features in generating iCBT impacts. Adjunct support was identified as an important aspect of context that may have complemented certain PSD features in reducing users’ anxiety.
This synthesis generated context-mechanism-outcome configurations (hypotheses) about the potential function, combination, and impact of iCBT program components thought to support desired program effects. We suggest that, when delivered with adjunct support, PSD features may contribute to reduced anxiety for child and adolescent users. Formal testing of the 11 configurations is required to confirm their impact on anxiety-based outcomes. From this we encourage a systematic and deliberate approach to iCBT design and evaluation to increase the pool of evidence-based interventions available to prevent and treat children and adolescents with anxiety.
Anxiety is one of the most common and early emerging mental health concerns for children and adolescents [
iCBT is a complex intervention [
To date, considerable variety exists in terms of how the 3 iCBT components have been incorporated into iCBT program design. Only 2 studies of iCBT effectiveness have attempted to identify or explain what program components can be used to optimize the therapeutic gains of users and for what reasons. Calear et al [
The realist synthesis provided us with a mixed methods approach to generate proposed explanations (hypotheses) of how and why iCBT programs work despite variations in its design and delivery [
We started the synthesis with the generation of a list of
We used the PSD model to identify PSD features (mechanisms) hypothesized to produce anxiety symptom changes (outcomes) in iCBT programs and recorded these as mechanism-outcome dyads. We then considered the program design and delivery features (context) that might support the operation of the mechanism-outcome dyads and combined them in unified but distinct configurations. The result was 8 candidate context-mechanism-outcome configurations (
We required diverse literature to inform this synthesis. We sought to include primary or secondary studies of iCBT interventions, conference proceedings, websites, program evaluations, and government or technical reports. We used 3 search strategies to identify this literature: (1) a systematic, comprehensive search of 8 electronic databases from disciplines relevant to the topic (ie, medicine and psychology)—Medline, Embase, Education Resources Information Center, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, ProQuest Dissertations & Theses Global, and PubMed for the period from 1990 to 2017, conducted by an information specialist; (2) a manual search using an internet search engine (Google) and gray literature repositories (eg, Association for Computing Machinery Digital Library, Open Gray, Institute of Electrical and Electronics Engineers Digital Library, and Canadian Agency for Drugs and Technologies in Health); and (3) a hand search of medical informatics journals (
We were interested in including documents relevant to iCBT programs that were designed for use by children or adolescents aged ≤19 years diagnosed with an anxiety disorder(s) or with anxiety symptoms associated with a disorder as classified according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [
During the document selection progress, 2 reviewers (authors ADR and LW) independently applied the inclusion criteria using a 2-stage approach. In stage 1, titles and abstracts of documents were screened for potential eligibility (
Quality appraisal of included documents involved assessing relevance to the synthesis objectives and, in the case of research studies, assessing methodological rigor. A total of 2 reviewers (authors ADR and LW) conducted the quality appraisal. Relevance was assessed by reviewing a document’s
To understand the quality of the research studies that provided outcome data for the synthesis, the methodological rigor of studies was assessed using the Mixed Methods Appraisal Tool (MMAT) [
To identify context-mechanism-outcome configurations, we extracted and coded iCBT program data using a data matrix with 6 major domains: (1) document characteristics (eg, study design), (2) participant characteristics (eg, demographics) and study procedures (ie, eligibility criteria), (3) context of iCBT delivery including a program’s targeted level of prevention according to the Institute of Medicine (IOM) model [
We used the PSD model [
Analysis was conducted at the program level [
We analyzed the candidate context-mechanism-outcome configurations in 4 stages using meta-ethnographic [
The 4 stages of the realist analysis and synthesis process of internet-based cognitive behavioral therapy (iCBT) programs for children and adolescents with anxiety. PSD: persuasive systems design.
In stage 3, we developed descriptions of how the iCBT program components were linked in our configurations. The descriptions focused on the proposed function (role) of key PSD features in explaining how iCBT programs might reduce anxiety for children and adolescents. To do this, we nested the configurations within our broader understanding of the theoretical underpinnings of the PSD model and CBT, along with original authors’ descriptions of the design or delivery of program features. This process allowed us to explore not only
Flow diagram of the literature search and selection process.
Details of the quality appraisal are provided in
MMAT scores were calculated for 35 research studies: 20 randomized controlled trials, 5 nonrandomized studies, 7 quantitative descriptive studies, 1 qualitative study, and 2 mixed methods studies. A total of 22 documents met all 4 MMAT criteria (100%), 7 documents met 3 criteria (75%), 5 documents met 2 criteria (50%), and 1 document met 1 criterion (25%). Lower MMAT ratings were a result of factors such as incomplete outcome data or unacceptable response rates, high withdrawal rates, or no mention of whether groups were comparable.
Overview of internet-based cognitive behavioral therapy user, program, and delivery characteristics.
Numbered list of programsa | Target users’ age group and symptom severityb | Program delivery | Therapist support in program | Adjunct program support | |||||||||||||||||||
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Use setting | # of sessions, frequency, or duration of program | Web or email | Phone | In-person |
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(1) BRAVE-Online | Children and adolescents with an anxiety disorder | Home | 10 weekly sessions plus 2 booster sessions; 60 min each | Xc | X | —d | Parent | |||||||||||||||
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(2) iCBTe for dental anxiety | Children and adolescents with an anxiety disorder | Home plus clinic | 12 weekly modules | X | — | — | Parent, dental professionalf | |||||||||||||||
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(3) Internet-delivered CBTg for children with anxiety disorders | Children with an anxiety disorder | Home | 11 modules over a 10-week period | X | X | — | Parent | |||||||||||||||
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(4) Internet-delivered CBT for children with specific phobia | Children with an anxiety disorder | Home | 11 modules over a 6-week period; 15-45 min each | X | X | — | Parent | |||||||||||||||
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(5) Chilled Out | Adolescents with an anxiety disorder | Home | 8 modules over a 12- or 14-week period; 30 min each | — | X | — | Parent (optional) | |||||||||||||||
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(6) Group therapy supported iCBT for adolescents with social anxiety disorder | Adolescents with an anxiety disorder | Home plus clinic | 12 weekly modules | X | X | X | Parent | |||||||||||||||
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(7) iCBT for anxiety disorders among adolescent girls | Adolescents with an anxiety disorder | Home | 7 modules over a 3-month period; 1 hour daily | X | — | — | — | |||||||||||||||
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(8) Internet cognitive behavioral skills-based program | Children with moderate-to-severe anxiety symptoms | Home | 3 modulesh with 20 sections over a 12-week period | — | X | — | Parent | |||||||||||||||
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(9) Internet-supported brief CBT for shy-socially isolated problem | Adolescents with moderate-to-severe anxiety symptoms | School | 6 modules | X | X | — | — | |||||||||||||||
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(10) STAY COOL system for test anxiety | Adolescents with mild-to-moderate anxiety symptoms | School or home | 6 modules over 8 weeks; 20-30 min for each activity | — | — | X | Researcheri | |||||||||||||||
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(11) Feeling Better | Adolescents with mild-to-moderate anxiety and/or depressive symptoms | Home | 4 modulesj | X | X | — | — | |||||||||||||||
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(12) Individually tailored iCBT for adolescents | Adolescents with mild-to-severe anxiety and/or depressive symptoms | Clinic | 6-9 prescribed modules over a 6- to 18-week period | X | X | X | — | |||||||||||||||
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(13) The e-couch Anxiety and Worry Program | Adolescents with no symptoms required | School | 6 weekly sessions; 30-40 min each | — | — | — | Teacherk, mental health service providerl | |||||||||||||||
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(14) MoodGYM | Adolescents with no symptoms required | School | 5 weekly modules; 30-60 min each | — | — | — | Teacherk | |||||||||||||||
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(15) Thiswayup Schools for Anxiety and Depression prevention courses | Adolescents with no symptoms required | School | 6 (anxiety) or 7 (depression) weekly modules; 40 min each | — | — | — | Teacherk |
aCategorized according to the Level of Prevention Model [
bChildren: mean study age of users ≤12 years; adolescents: mean study age of users ≥13 years. The anxiety severity reported was the severity required for study inclusion; anxiety severity was not necessarily the baseline level of symptoms participants had.
cThis type of therapist support was incorporated.
dThis type of adjunct support was not incorporated.
eiCBT: internet-based cognitive behavioral therapy.
fA dental professional (a dentist, dental hygienist, or dental assistant) provided exposure at a dental clinic.
gCBT: cognitive behavioral therapy.
h2 blocks of modules (containing 9 major sections) are dedicated to mothers, and 1 module block (containing 12 major sections) is dedicated to the child plus mother.
iResearch assistant or graduate student was present to facilitate aspects of the study, such as assessment and troubleshoot technical issues.
jThe first 4 out of a possible 12 modules were delivered for the purpose of this study: Introduction, Activity and Motivation, Thoughts and Feelings, and Stress Management [
kProgram administration was facilitated by a classroom teacher. The teacher was available for general guidance but did not provide an active therapeutic role in the program.
lA mental health service provider was present in 1 study of the program to facilitate program administration and address student questions [
Treatment programs incorporated the most PSD features, followed by indicated prevention and then universal prevention programs. Out of the 4 PSD support categories, features from the primary task support and dialogue support categories were most widely used. In terms of primary task supports, iCBT programs of all IOM program types incorporated reduction and tunneling to regulate the logical and incremental presentation of module content to users, mimicking the progressive delivery format of face-to-face CBT. Self-monitoring of users’ iCBT progress was also a primary task support feature common to all programs. Social role, a dialogue support feature, created a virtual presence of
Frequency of the cognitive behavioral therapy (CBT) content and persuasive systems design features across 15 internet-based cognitive behavioral therapy (iCBT) programs, organized according to program type.
Across program types, there was an overall trend for reduced anxiety symptoms among children and adolescents who received iCBT. An overview of the outcomes is provided in
We found that reductions in anxiety outcomes were reported across iCBT programs with many shared mechanisms and delivery contexts. Self-monitoring, simulation, social role, similarity, social learning, and rehearsal were common PSD features across all program types; however, mechanisms for customizing program content (ie, personalization and tailoring) distinguished treatment, indicated prevention, and universal prevention programs from one another. The key aspect of iCBT context that supported the mechanism-outcome interactions was adjunct support. The adjunct support person (eg, therapist, parent, and teacher), their expertise, and the intensity and frequency of their communication (eg, weekly personalized feedback and technical troubleshooting as needed) was associated with the program type, and, therefore, also the characteristics of users, such as age and symptom severity. In this way, treatment programs received the greatest amount of adjunct support relative to indicated and universal prevention programs.
The refined set of context-mechanism-outcome configurations is summarized in
Summary of the 11 context-mechanism-outcome configurations for internet-based cognitive behavioral therapy programs for children and adolescents with anxiety.
Context—user characteristics and adjunct support | Mechanisms—PSDa features and proposed function | Outcomes—trend in anxiety changes, pre- to postinterventionb | Contributing programs | Mean MMATc score, % | Supporting studies where reductions of anxiety were foundd, % | ||
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Configuration 1 | Self-monitoring: to increase users’ attention to and comprehension of anxiety-related feelings or behaviors, track and present users’ program progress toward anxiety management or symptom reduction, and assess users’ accumulation of program-related knowledge | Reductions in user- and parent-reported symptoms, diagnoses, and clinical severity | Programs 1-7 | 88 | 98.5 |
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Configuration 2 | Simulation + social role + similarity + social learning: to normalize users’ experience of anxiety and increase motivation or willingness to improve their mood and model the application of new anxiety management skills | Reductions in user- and parent-reported symptoms, diagnoses, and clinical severity | Programs 1-6 | 91 | 97.4 |
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Configuration 3 | Rehearsal: to provide opportunities for developing fear tolerance, reduction, and/or extinction and reinforce the application of program concepts, behavioral anxiety management strategies, and problem-solving skills | Reductions in user- and parent-reported symptoms, diagnoses, and clinical severity | Programs 1-7 | 88 | 98.5 |
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Configuration 4 | Personalization + social role + trustworthiness + expertise + authority: to provide customized feedback on user’s program activity to increase accurate comprehension and application of anxiety management concepts and skills | Reductions in user- and parent-reported symptoms, diagnoses, and clinical severity | Programs 1-6 | 91 | 98.5 |
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Configuration 5 | Self-monitoring: to increase users’ attention to and comprehension of anxiety-related feelings or behaviors, track program progress toward anxiety management/symptom reduction, and assess users’ accumulation of program-related knowledge | Reductions in user- and parent-reported symptoms and diagnoses | Programs 8-12 | 89 | 100 |
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Configuration 6 | Simulation + social role + similarity + social learning: to normalize users’ experience of anxiety and increase motivation or willingness to improve their mood and model the application of new anxiety management skills | Reductions in user- and parent-reported symptoms and diagnoses | Programs 8 and 11 | 100 | 100 |
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Configuration 7 | Rehearsal: to provide opportunities for developing fear tolerance, reduction, and/or extinction and reinforce the application of program concepts, cognitive and behavioral anxiety management strategies, and problem-solving skills | Reductions in user- and parent-reported symptoms and diagnoses | Programs 8-12 | 89 | 100 |
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Configuration 8 | Tailoring: to adapt program content based on user’s demographic or mental health condition to improve the relevance for each user | Reductions in user-reported symptoms and diagnoses | Programs 11 and 12 | 100 | 100 |
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Configuration 9 | Self-monitoring: to increase users’ attention to and comprehension of anxiety-related feelings or behaviors, track and present users’ program progress toward anxiety management or symptom reduction, and assess users’ accumulation of program-related knowledge | Reductions in user-reported symptoms | Programs 13-15 | 70 | 83.3 |
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Configuration 10 | Simulation + social role + similarity + social learning: to normalize users’ experience of anxiety and increase motivation or willingness to improve their mood and model the application of new anxiety management skills | Reductions in user-reported symptoms | Programs 13-15 | 70 | 83.3 |
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Configuration 11 | Rehearsal: to provide opportunities for developing fear tolerance and reinforce the application of program concepts, cognitive and behavioral anxiety management strategies, and problem-solving skills | Reductions in user-reported symptoms | Programs 13 and 14 | 75 | 80 |
aPSD: persuasive systems design.
bCategorized according to type of anxiety measure used, although specific instruments varied among studies.
cMMAT: mixed methods appraisal tool.
dPercentage of studies reporting a reduction in anxiety for internet-based cognitive behavioral therapy participants from pre- to postintervention.
Treatment programs for children with an anxiety disorder, delivered with adjunct therapist, parent, or professional support and include self-monitoring, may produce postintervention reductions in user’s anxiety (diagnoses, clinical severity, self-reported, and parent-reported symptoms). Self-monitoring was part of the workflow for each module of the BRAVE-Online program and included regular tracking of symptoms and interactive activities and end-of-module quizzes to “facilitate attention and comprehension of material” [
Treatment programs for children with an anxiety disorder, delivered with adjunct therapist, parent, or professional support and include simulation with a social role, similarity, and social learning features, may produce postintervention reductions in user’s anxiety (diagnoses, clinical severity, self-reported, and parent-reported symptoms). These features were evident in videos or animations of peers, cartoon, and real-life characters to illustrate the experience of different emotions and the application of therapeutic skills, such as goal setting, developing fear hierarchies, and completing exposure activities [
Treatment programs for children with an anxiety disorder, delivered with adjunct therapist, parent, or professional support and include rehearsal features, may produce postintervention reductions in user’s anxiety (diagnoses, clinical severity, self-reported, and parent-reported symptoms). Rehearsal was incorporated in brief, interactive tasks to be completed during the module (eg, drag this sentence to the correct term and drop it there) [
Treatment programs for children with an anxiety disorder, delivered with adjunct therapist, parent, or professional support and include personalization, a social role, trustworthiness, expertise, and authority, may produce postintervention reductions in user’s anxiety (diagnoses, clinical severity, self-reported, and parent-reported symptoms). Personalization provided a sense of program relatedness or knowing of the user through automated or manual features based on demographic details or program activity of the user. For example, the user’s name and that of his or her adjunct therapist could be populated throughout the modules [
Indicated prevention programs for children or adolescents with mild-to-severe anxiety symptoms, delivered with adjunct therapist, parent, or researcher support and include self-monitoring, may produce postintervention reductions in user’s anxiety (diagnoses, self-reported, and parent-reported symptoms). Self-monitoring was incorporated in the Feeling Better program using standardized symptom assessments at the beginning of modules as a way “to monitor symptom change” [
Indicated prevention programs for children or adolescents with mild-to-severe anxiety symptoms, delivered with adjunct therapist, parent, or researcher support and include simulation with a social role, similarity, and social learning, may produce postintervention reductions in user’s anxiety (diagnoses, self-reported, and parent-reported symptoms). Simulation was incorporated in examples or demonstration videos of individuals (social role) “illustrat[ing] certain concepts in the program” [
Indicated prevention programs for children or adolescents with mild-to-severe anxiety symptoms, delivered with adjunct therapist, parent, or researcher support and include rehearsal, may produce postintervention reductions in user’s anxiety (diagnoses, self-reported, and parent-reported symptoms). The STAY COOL program described including evidence-based practice activities (rehearsal) for reducing physical and cognitive test anxiety symptoms and pairing these coping activities with desensitizing exposure tasks to improve the program’s effectiveness [
Indicated prevention programs for children or adolescents with mild-to-severe anxiety symptoms, delivered with adjunct therapist, parent, or researcher support and include tailoring, may produce postintervention reductions in user’s anxiety (diagnoses, self-reported, and parent-reported symptoms). iCBT content was tailored according to the user’s symptom profile. In the Feeling Better program, “A standardized assessment of symptoms of distress… [was] built into the start and end of core program modules to monitor symptom change and to help the user choose customized streams of program content specific to their emotional distress [such as anxiety, depression, or stress]” [
Universal prevention programs for adolescents with minimal or no symptoms, delivered with teacher facilitation and include self-monitoring, may produce postintervention reductions in user’s self-reported anxiety symptoms. The MoodGYM program provided anxiety and depression quizzes (self-monitoring) before and after each module. Adolescents’ answers to quizzes and other program tasks were saved in a
Universal prevention programs for adolescents with minimal or no symptoms, delivered with teacher facilitation, and include simulation with a social role, similarity, and social learning, may produce postintervention reductions in user’s self-reported anxiety symptoms. Cartoon vignettes (similarity and social role) provided examples of anxiety management behaviors and responses as a regular part of the modules (simulation and social learning). For example, at the beginning of the MoodGYM program, adolescent users were “introduced to six distinct characters that form the basis of examples and discussion. Each character has a specific way of dealing with stressful situations, which [were] explored in the program.” [
Universal prevention programs for adolescents with minimal or no symptoms, delivered with teacher facilitation, that include rehearsal may produce postintervention reductions in user’s self-reported anxiety symptoms. The e-couch Anxiety and Worry program included rehearsal exercises
Our study systematically documented important similarities and differences in the design and delivery of iCBT components across 15 existing programs, which to our knowledge, is the first study of its kind for children or adolescents with anxiety. Anxiety reductions were reported in more than 98% of studies we reviewed. Our use of realist synthesis methods enabled the development of 11 context-mechanism-outcomes configurations that hypothesized the PSD features (technology-based mechanisms) that might contribute to the observed reductions in anxiety symptoms (outcomes), as they relate to key user and delivery features (context). Our results point to the need for increased emphasis on PSD in the development, evaluation, and reporting of iCBT programs for children and adolescents with anxiety concerns and further research designed to establish their relationship with improved anxiety symptomatology.
The 11 configurations included PSD features from all 4 support categories. However, some category features were more often linked to iCBT program effects than others. Our findings highlight the central role of primary task supports in iCBT interventions for children and adolescents with anxiety, followed by dialogue support and system credibility support categories. Only 1 social support feature was supported by our analysis. These findings are in line with others [
All iCBT programs in this study contained multiple PSD features. Although detailing the frequency of PSD features in iCBT provides some insight into what a user does within a program (activity), this information does not describe the important patterns or combinations of PSD features or explain why a program may or may not be effective. However, our findings suggest that (1) no PSD feature is applied in isolation and will likely not
Overlap with the proposed context-mechanism-outcome configurations we generated and the literature on internet-based interventions indicate larger patterns for how these features operate. For example, others have hypothesized that self-monitoring might be used to increase user’s knowledge, self-awareness, and ability to monitor and manage their health [
The consistent incorporation of specific key PSD features (rehearsal, self-monitoring, and simulation) in configurations across all program types indicates that these may be
Differences in key PSD features may distinguish iCBT programs of one program type from another (ie, indicated prevention programs used tailoring whereas treatment programs used personalization). It has been recognized that user characteristics (eg, symptom severity and motivation), the focus of a program (eg, technological or therapeutic elements incorporated and the
Realist synthesis methods focus on uncovering both the mechanisms of a complex intervention and their relationship to context [
School-based universal prevention programs have aspects of context (ie, setting of program use) that are different from indicated prevention and treatment programs, making their design and delivery unique [
We took a high-level perspective to develop hypotheses that may explain the effects of iCBT as a complex intervention. To our knowledge, this is the first study to systematically describe what and how PSD features may relate to symptom reductions in iCBT across programs for children and adolescents with anxiety. Although our findings may be similar to those of adult-based studies of internet-based interventions (eg, rehearsal [
This review has several strengths. We followed established and rigorous methods for conducting and reporting realist syntheses [
Several challenges placed limitations on our findings. The 11 context-mechanism-outcome configurations we developed were dependent on the level of detail provided in the documents included in this synthesis. iCBT program descriptions were brief and details around therapeutic or technological features used (and associated theory or justification) were limited. Thus, the specifications of each technological (PSD) feature are not accounted for with our approach (which required a high level of abstraction) and readers should consider that the differences within features of the same type may be just as large as the differences across feature types (eg, rehearsal activities may differ among iCBT programs but these differences are not included in our configurations). We hope the hypotheses that we have generated can be applied to more detailed studies in the future that explore this important issue. In addition, few ineffective interventions (those that did not generate anxiety reductions) were identified for our review; therefore, we were unable to explore aspects of the delivery context or PSD features that might contribute to undesirable treatment effects with iCBT. As the dissemination and use of reporting standards (eg, Consolidated Standards of Reporting Trials–eHealth [
As more complex and sophisticated technological mediums or delivery methods (ie, mobile phones and wearables) and features (ie, gamification, virtual reality, and virtual agents) are being developed and incorporated into new technology-based treatments, we need to understand the
First, studies designed to assess the impact and functions of identified program components and identify other components that are relevant for the design of new iCBT programs for children and adolescents with anxiety are needed. Evaluating individual program features to understand their theoretical level of action (what the feature intends to do; eg, based on CBT or the PSD model), instantiation (how the feature was executed; eg, timing and volume), quality (a distinguishing aspect of the feature; eg, degree of personalization, size, or color), and their effect (the result or consequence of a feature; eg, initiating and reinforcing behavior) [
Evaluation of individual features requires the use of certain methodological frameworks [
Second, to advance our understanding of the causal mechanisms that underpin effective iCBT programs, we will need to address what and how therapeutic content (ie, CBT skills) is delivered using PSD (technology-based) features to produce the intended and actual attitude or behavior changes. This will involve developing a framework that integrates the PSD model with the CBT framework and a theory of behavior change (for a review of theories see [
Although iCBT effectiveness for children and adolescents with anxiety has been demonstrated, not all programs benefit users in the same way. This leaves room for programs to be further optimized. PSD (technological) features can be intentionally selected and incorporated into the design and delivery of iCBT programs, making it an aspect of treatment that is under the control of developers. The hypotheses that we generated suggest that multiple key PSD features may work together to help users actively engage with therapeutic content and practice newly acquired skills. The type and degree of adjunct support will vary based on the level of prevention and user characteristics (ie, symptom severity) the program was designed to target and can influence what and how certain features operate within the program. The key PSD features and aspects of context identified require formal testing to understand whether, and to what extent, they are effective and how they function. These next steps may involve new conceptualizations of effectiveness and evaluation methods. As we improve our understanding of how the components of iCBT work (their proposed purpose) and what users prefer and need, we can create programs with better objective and subjective effectiveness. This systematic and deliberate approach to iCBT design and evaluation will increase the pool of evidence-based interventions available to prevent and treat anxiety in children and adolescents.
The persuasive systems design (PSD) model.
The candidate Context-Mechanism-Outcome configurations.
Document electronic search strategy.
The level of contribution and methodological quality of documents included in the synthesis.
Overview of the preintervention to postintervention changes in anxiety (outcomes) based on the total number of measures, studies, and iCBT programs across program types.
American Academy of Child and Adolescent Psychiatry
cognitive behavioral therapy
Canadian Institutes of Health Research
electronic health
internet-based cognitive behavioral therapy
Institute of Medicine
Mixed Methods Appraisal Tool
persuasive systems design
The authors of this review would like to thank the original authors who responded to our request for more information about their iCBT program. The authors also thank Robin Featherstone for developing the search strategy and conducting the electronic database search. This research was supported by a Canadian Institutes of Health Research (CIHR) grant (Knowledge Synthesis Grant CIHR: KRS2014) awarded to ASN (principal investigator). During the conduct of this review, ASN and LH held CIHR New Investigator Awards and PM held a Tier 1 Canada Research Chair in Child Health. ADR received a graduate studentship award from Alberta Innovates and the Women and Children’s Health Research Institute.
None declared.