Roughly 7% of children and adolescents in the U.S. have received an anxiety diagnosis. Untreated anxiety disorders have been linked to an increased risk of depression, problems at school, and substance use disorder, yet as many as 40% of young people with a diagnosis don't receive treatment.
Stigma and shame, a mistrust of healthcare institutions, cultural norms or language gaps, an inability to leave work or school to attend appointments, and a severe national shortage of child and adolescent psychiatrists are all factors that keep children and young adults from receiving the treatment and support they need. In recent years, mental healthcare deserts — areas, most often rural or isolated settings, where access to professionals who treat mental illness is low — have drawn the attention of the medical community.
“The data shows that anxiety is increasing across demographics and in children and teenagers,” says Lisa Fortuna, MD, MPH, director of child and adolescent psychiatry at Boston Medical Center. “We need to better understand treatment barriers, and determine how we can ensure that patients can access treatment that is effective and appealing to them.”
To break down barriers to anxiety treatment and bring greater equity to pediatric behavioral healthcare, researchers and providers are investigating innovative ways of delivering effective treatment such as cognitive behavioral therapy (CBT), a highly structured and proven standard of care. Providers have begun using telehealth, apps, online software and games, and even text messaging to deliver CBT and other anxiety interventions to young people, under the assumption that these digital approaches will be effective with a generation comfortable with technology.
While technology seems to be a key tool in breaking down access barriers and multiplying our capacity to treat people in areas where providers are less available, research has yet to fully support its widespread use for anxiety, says Fortuna, who also notes concerns about the evidence and credentials behind many mental health apps. And with increasing attention given to disparities, it becomes important to determine if digital treatments, which may be easier to deliver to underserved populations, are acceptable substitutes for face-to-face care.
Do improved outcomes mean equal outcomes?
To address these open questions, the Patient-Centered Outcomes Research Institute (PCORI) recently granted more than $12 million in funding for a clinical trial called Kids FACE FEARS (Kids Face-to-face And Computer-Enhanced Formats Effectiveness study for Anxiety and Related Symptoms), a nationwide study with sites in Massachusetts, Maryland, Florida, and Washington state. Led by Fortuna, along with co-PI Donna Pincus, PhD and co-investigators Michelle Porche, EdD and Jonathon Comer, PhD, the study will be the first to compare the effectiveness of face-to-face and online methods of evidence-based CBT for children and adolescents who have difficulty accessing care for a variety of reasons.
Kids FACE FEARS will deliver treatment through two modalities. Treatment for the in-person group is delivered by frontline providers in pediatric health settings who, as part of the program, receive remote consultation from experts in CBT for youth anxiety. Families assigned to the online CBT group complete self-administered web modules of the same materials, and will also participate in brief biweekly phone calls from a therapist that provide supportive accountability and facilitate use of the modules.
The centerpiece of Kids FACE FEARS is the Cool Kids suite of CBT-based programs for youth anxiety, which was founded in Australia in the mid-1990s. It’s been shown to teach children, teenagers, and their parents practical skills on how to better manage anxiety, fearful thoughts, tense physical feelings, and avoidant behaviors. But Fortuna and her team are interested to find if they can replicate the positive results seen in other studies.
“Cool Kids is an evidence-based program, but it was established with a majority white population with higher literacy rates. Our population is going to be so different,” explains Fortuna, who notes that non- English-speaking populations have not been very well represented in research. Kids FACE FEARS will offer interventions in both English and Spanish and include historically underserved and underrepresented populations.
Previous research has shown that CBT can be equally effective in non-white, non-English-speaking populations, Fortuna says. Many patients who receive CBT see improved symptoms in as few as four sessions, she adds, but many also don't make it that far.
"We’re working to learn how to get people to that dose, so to speak,” Fortuna says. “We’re excited about the online modules because they could be a way that even patients with greater barriers can get more than four sessions and hit treatment with fidelity."
Comparing CBT delivery methods for anxiety could open access opportunities
For each patient, outcomes will be assessed across a two-year follow-up period. Study findings will compare outcomes between these two supported treatment formats and explore whether certain factors — such as internet access, distance to clinic, other mental health problems, and comfort with technology — may differentially influence the effectiveness of each of these CBT formats.
The outcomes from Kids FACE FEARS could substantively impact the adoption of digitally delivered interventions to pediatric patients in the future, and also provide insight into the ability of children and young adults to self-direct some of their care.
While Fortuna and her colleagues are optimistic and enthusiastic about the important role that technology can play to help bridge gaps in care for youth with anxiety, they are quick to note that some patients and families have pushed back against the notion that just because an intervention is digital that young people will adopt it immediately.
“As we would with any research study, we are approaching Kids FACE FEARS with an open mind as to whether face-to-face and online CBT formats are equally effective treatments and how young people feel about replacing physical interaction with digital interaction,” says Fortuna. “This study also allows us a window into the broader question of how the healthcare system as a whole interacts with digital options, which is really exciting and important for us to continue to explore.”