1. Address Correspondence to:
The Clinical Utility of iPhone Technology for Pediatric Pain Management Kelly Smith1,2, Christina Iversen, B.A. 1, and Rachael Coakley, Ph.D.1,3 1Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital 2Emmanuel College, Boston, MA 3Department of Psychiatry, Harvard Medical School, Boston, MA
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Abstract
Methods
The present study systematically reviewed 89 Apple applications targeting pediatric chronic pain interventions; 73 of those were purchased and tested. Each application that was purchased was independently rated by three raters on a Likert scale from 1 (poor) to 5 (excellent) in six  different categories. Thirteen applications included discrepant ratings in one or more categories. These apps were coded by two additional raters to increase reliability. Applications were also coded into categories based on an application’s main utility.
Of the 73 purchased and reviewed applications, 25 were recommended based on whether they obtained a mean rating of “4” (very good) or better in this systematic review. While the majority of these applications were found to be developed by lay-professionals, target adult populations, and have not been subject to clinical research, a significant number of these applications are engaging and well designed.
This review highlights the current applications that may be clinically useful in pediatric populations, but also highlights the need for more research and the need for caution in using applications with patients.
Applications were identified using the following search terms: “Apple applications for: relaxation, breathing, diaphragmatic breathing, belly breathing, guided imagery, pacing breathing, kids, sleep, hypnosis, self-hypnosis, anxiety, yoga, biofeedback, pain, CBT, and cognitive-behavioral therapy.” This search yielded a total of 89 applications. Sixteen were eliminated prior to review because they either exceeded our price limit of $6.00 per app or were found to be outside the scope of this clinical review.
Remaining apps (n = 73) were rated on a Likert scale (1=poor, 5=excellent) in six domains.
Child/adolescent appropriate
Educational
Skills-based
Engaging
Ease of use
Technical reliability
Three raters coded each application. Ratings that were discrepant by two or more points on a Likert scale were then coded by two additional independent raters.
Additional information gathered about each application includes price, developer, year it was created, overall characteristics, and user reviews if available.
Discussion
Strengths
This study offers the first comprehensive review of iPhone app technology for use in clinical pediatric psychology practice.
The apps contained in this review may offer clinical benefit to a wide range of pediatric illness and pain populations.
Approximately 1/3 of the tested apps were found to be consistent with skills that are taught as part of an evidence based CBT approach to pain management, despite being developed by lay professionals.
Many apps were also found to be child and adolescent friendly, despite being developed for adults.
This study finds that of 73 potentially relevant apps, only 25 (34%) are likely appropriate for children and adolescents and include a component of clinical utility.
This research provides clinicians a guide to the most useful applications available at this time.
A complete list of recommended apps is available by request.
Limitations and Future Directions
This study offers subjective ratings completed by three Ph.D. level providers and two undergraduate research assistants. In general, there was high agreement between raters, though official rater-reliabilities have yet to be calculated.
Testing these applications in child and adolescent populations will yield additional useful information about the clinical utility and benefit of integrating iPhone technology into pediatric psychology practice.
Evaluating applications in other operating systems such as Android, Windows, and Blackberry could give more insight into other available tools that can be used with a wider audience.
Background
Cognitive behavioral skill development that includes biobehavioral training is demonstrated to be an effective approach for youth with a variety of chronic pain conditions (Chen & Francis, 2010).
Routine practice of these skills is a necessary component of treatment for children and adolescents in order to gain proficiency with these techniques.
iPhone technology may offer an engaging and rewarding platform that could potentially reinforce skill acquisition through home-based practices as well as offering the potential for self-management of symptoms.
Research on clinically useful applications will help clinicians integrate technology into their practice, which may be especially attractive to children and adolescents.
In 2012, 50% of all US households owned an average of three Apple products (CBNC’s All-America Economic Survey, 2012), making apple the most widely utilized app-oriented technology.
To date, the only published study looking at smartphone applications for pain management tested only five applications for clinical utility (Rosser & Eccleston, 2011).
The current research offers the first systematic review of iPhone apps that may offer clinical utility for children and adolescents with chronic pain and associated difficulties.
Results
Of the 73 purchased applications, 25 were recommended.
Recommendations were made based on whether or not each application received a mean rating of “4” (very good) or better in each of the categories.
A sample of recommended applications:
Relax and Rest Guided Meditations
Breathe2Relax
iSleep Easy
Autogenic Training and Progressive Muscle Relaxation
Super Stretch Yoga
Camp Pain Retreat
CBT-i Coach
The majority of apps were found to either not be developmentally appropriate for use in child and adolescent populations and/or contained information that was not consistent with evidence based practice in pediatric psychology.
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