The use of computerised CBT with children and young people: The ‘Think Feel Do’ programme SOPHIE: Mr Thomas Richardson & Ms Sophie Velleman, Assistant Psychologists Prof. Paul Stallard, Consultant Clinical Psychologist Avon and Wiltshire Mental Health Partnership NHS Trust/ School for Health, University of Bath

Assess views of children, young people and parents about cCBT Aims of TFD project Systematic review of use of cCBT with children with mental health problems Assess views of children, young people and parents about cCBT Pilot study of cCBT for those on CAMHS waiting list Survey of clinician’s views about cCBT SOPHIE:

Why is cCBT useful for children? High levels of technology use and competence Computers, internet, mobile phones all have potential Long waiting lists for CAMHS in UK cCBT offers: Familiar media Greater accessibility Deliver in range of settings (such as schools) Avoid potential face to face embarrassment Treatment option for mild/moderate problems SOPHIE:

Aim 1: Systematic Review of use of cCBT with children 10 papers found- only 4 control group RCTs 5 different Interventions: ‘Stressbusters’, ‘Master your mood online’, ‘CATCH-IT’, BRAVE-Online’, MoodGYM’ 5 to 14 cCBT sessions, 15-90 minutes each Level of supervision varied Significant reductions in clinical symptoms Improvements in diagnostic status and functioning Moderate-high satisfaction Conclusion: Encouraging but little research at present TOM: cCBT for prevention and treatment of depression /anxiety in young people 10 papers found- only 4 control group RCTs, some case series Range of ages but mainly older adolescents 5 to 14 cCBT sessions, 15-90 minutes each Level of supervision varied- some without supervision, some contact via email, phone, text, other teacher present. Interactive and multimedia- one group CBT via chat room Significant reductions in clinical symptoms: anxiety and depressive symptoms Improvements in diagnostic status and functioning: 30-78% no longer meet criteria, reduced number of diagnoses, improved self-esteem, cognitions and strengths. Moderate-high satisfaction: for both children and parents, though concerns about length and difficulty. Spence et al- similar to face-to-face Conclusion: Encouraging but little research at present- sparse when compared with adults. Little on attitudes- this is where we come in

Aim 2: Assess views of children, young people and parents about cCBT Method Aim: to evaluate attitudes towards computerised therapy in children and adolescents and their parents attending Child and Adolescent Mental Health Services Self-report questionnaires developed Recruitment via CAMHS outpatient service Participants: 31 parents, 37 young people TOM: - Self-report questionnaires were developed for parents and young people to examine attitudes towards computerised therapy. - Recruitment was made via a Tier 3 CAMHS outpatient service. - All young people and their parents deemed suitable by staff who attended an appointment over a 2 week period were approached. - Of those approached, one child refused to take part because they did not have enough time and five adults refused because they were too busy or did not use computers. - A total of 31 parents and 37 young people completed the questionnaire. - Age 8 to 17 years with a mean of 14.5 years. - 17 were males and 17 females.

Young Peoples Views High levels of computer use High levels of online help seeking Few found this information helpful Low-moderate attitudes towards computerised therapy Many sceptical or undecided Few would prefer over face-to-face Minority wanted to use alone TOM: Computer usage - All but one young person had access to a computer at home - 58% had their own computer. - 73% used for 3 hours a week or more - Range of daily activities, mainly: Social networking (58%), Internet searches for information (54%) Help-seeking - 52% had used a computer or the internet to search for information about their worries, unhappiness or problems. - 47% had used a computer or the internet to find ways to cope or deal with their worries, unhappiness or problems. - 39% had used emails, chat rooms or social networking sites to talk about their problems or worries with others. However, was unhelpful: - However, just 21% found the information they obtained to be very helpful - 32% said it hadn’t helped at all - 65% had tried using these ideas to cope, but just 41% reported these were helpful. - 67% reported talking to others only helped a little Attitudes - When asked if they were interested in using computer program to help them with their worries and problems: - 24% were interested - 27% were not - 49% were undecided - 88% would prefer to use this at home - When asked about preferred course of treatment: - 49% meet and talk with someone in clinic - 9% use a computer program on their own - 9% meet and talk with someone as well as use computer program

Parents Views - Majority believed could help young people - Most interested in using it with their child- none opposed - Majority (67%) reported potential benefits Qualitative analysis revealed 5 themes: - Opportunities for peer support - Delivery via a familiar media - Anonymity - Independence/Encourage help-seeking - Ease of access to information TOM: - 61% felt that computer programs could help young people learn more about their problems and worries - 55% felt computer programs could help young people learn new ways to cope When parents were asked if they would want their children to try using a computer program to help them with their problems: - 74% responses positively - 26% were undecided - 0% said definitely no - 67% reported they felt there would be benefits of computerised therapy. - 5 main themes emerged: - Opportunities for peer support: Talk to others in same situation - Delivery via a familiar media: Young people used to using computers - Anonymity: - Avoids embarrassment - Independence/Encourage help-seeking: Allow them to make informed decisions - Ease of access to information: Find information they might not be able to get otherwise

Parents Concerns - Minority (32%) reported concerns Qualitative analysis revealed 5 themes: - Quality of information - Supporting negative behaviours - Safety and Security - Lack of face to face contact - Many related to the internet TOM: Only 32% identified concerns with computerised therapy. - 4 main themes emerged: - Quality of information: Getting incorrect advice - Supporting negative behaviours: Pro-anorexia websites - Safety and Security: Where information is coming from - Lack of face to face contact: Inappropriate as a replacement - Many related to the internet- might not be relevant to cCBT: Most program not online

Conclusions High computer use in those using CAMHS Online help-seeking common but not helpful Young people sceptical because of past experiences Parents more positive than their children Uptake low if offered as alternative to face-to-face Process of engagement is key TOM: - High levels of computer use in young people attending CAMHS - High levels of online help-seeking behaviours Clinicians should check young people have not obtained inaccurate and misleading information online - Majority do not find information found online useful- may be sceptical about cCBT because of this - Parents more positive- identify more benefits than concerned Majority of parents interested in computerised therapy for their child - Most preferred face-to-face CBT- low uptake if cCBT offered as an alternative to face-to-face Some expressed preference for using software by themselves- raises concerns over therapeutic relationship -Demonstrating software and engaging young person may enhance uptake

Aim 3-Pilot study of cCBT: Think Feel Do cCBT CD-Rom for treatment of mild/moderate depression and anxiety in children and adolescents age 11-16 Based on ‘Think Good- Feel Good’ Developed with the help of young people Delivered with help of facilitator Includes: Interactive quizzes, video clips, exercises Currently undergoing pilot RCT SOPHIE: - Developed with the help of young people in the local area- narrate and act in videos - Interactive and Multimedia. - Designed to be used with help of a facilitator such as teacher, nurse or assistant psychologist. - Psychoeducational - Cartoon characters narrating and guiding users through: - Quizzes - Self-help materials - Practices exercises - Video clips.

Think Feel Do- Session outline Session1: Introduction, Psycho-education, CBT, assessment and positive diary Cognitive Feelings Session 3: Link thoughts and feelings identify positive and negative thoughts Session 4: Identify thinking traps and change negative to positive Session 2: Emotional recognition & Links between feelings and situations Session 5: Emotional Management Behaviour SOPHIE: Session 6: Problem solving

Think Feel Do How do we increase uptake of Think Feel Do? Time for a video….. SOPHIE:

Aim 4- Clinicians attitudes to cCBT All previous work conducted regarding adults Important to know what CAMHS clinicians think: - Preferred method of delivery can be used - Estimate and increase uptake by services - Address concerns This is where you help us please! SOPHIE:

For more information - Email: Paul Stallard: P.Stallard@bath.ac.uk Sophie Velleman: S.Velleman@bath.ac.uk Thomas Richardson: T.H.Richardson@bath.ac.uk - Website: www.bath.ac.uk/health/mhrdu/ThinkFeelDo/Thinkfeeldo.html - Paper in press: Stallard, P., Velleman, S. & Richardson, T. Computer use and attitudes towards computerised therapy amongst young people and parents attending Child and Adolescent Mental Health Services (In press, Child and Adolescent Mental Health). SOPHIE: