Times are changing: digitalisation in child and adolescent psychotherapy

Triggered by the SARS-CoV2-19 pandemic, the establishment of digital health interventions (DHI) to treat children and adolescents with psychiatric disorders has been pushed forward with an astonishing velocity. General contact restrictions forced psychotherapists to treat their patients via DHI, especially video conferences. During the first months of the pandemic, acceptance of DHI greatly improved and the extension of technicaland IT infrastructure was propelled. DHI offer a broad spectrum of methods ranging from the augmentation of face-to-face therapy to stand-alone DHI. However, the accelerated DHI usage in psychotherapy prompts specific questions: For which groups of patients do evidence-based approaches exist? What are prerequisites and precautions? And: what are general advantages and pitfalls of DHI? This guest-editorial aims to outline the scientific state of research on DHI and to discuss practical aspects of DHI-related interventions in psychotherapy.

Triggered by the SARS-CoV2-19 pandemic, the establishment of digital health interventions (DHI) to treat children and adolescents with psychiatric disorders has been pushed forward with an astonishing velocity. General contact restrictions forced psychotherapists to treat their patients via DHI, especially video conferences. During the first months of the pandemic, acceptance of DHI greatly improved and the extension of technical-and IT infrastructure was propelled.
DHI offer a broad spectrum of methods ranging from the augmentation of face-to-face therapy to stand-alone DHI. However, the accelerated DHI usage in psychotherapy prompts specific questions: For which groups of patients do evidence-based approaches exist? What are prerequisites and precautions? And: what are general advantages and pitfalls of DHI? This guest-editorial aims to outline the scientific state of research on DHI and to discuss practical aspects of DHI-related interventions in psychotherapy.

Evidence-based DHI
Hollis and colleagues [1] summarized 21 former meta-analyses and reviews from the beginning of the development of DHI in the 1990s until the end of 2015 in their meta-review and additionally updated a systematic review analysing 30 randomized controlled trials (RCT) using DHI. Their review represents an outstanding comprehensive approach and has recently been complemented by a systematic literature search of our own work group [2], strictly following the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
The work by Hollis and colleagues and our own search revealed that most robust evidence exists for interventions for anxiety disorders and mild to moderate depression (especially computerized cognitive behavioural therapy (cCBT) approaches).
RCT for ADHD in children and adolescents revealed rather heterogeneous results which might be explained by their highly heterogeneous approaches. The studies ranged from neurofeedback trainings to executive functioning trainings and interventions targeting everyday organization and planning skills. They show comparable (inconsistent) effects to nonpharmacological face-to-face therapy [1,2].
Increasing evidence emerges for DHI targeting autism spectrum disorders which include DHI for children from preschool age to adolescence and their parents [1,2]. DHI for children and adolescents with ASD involve parents more frequently than DHI for other diagnoses.
Studies investigating DHI for other diagnoses such as eating disorders, psychosis, obsessive compulsive disorders, dyslexia, coordination disorders, conduct disorders with disruptive behaviour, tic disorders, insomnia or trichotillomania in children and adolescents are rather scarce. But the few available studies show promising results, though more high-quality studies are needed for a profound evaluation of DHI for those disorders.
Looking at the technical aspects, most studies use personal computers, which offer the broadest range of applications, ranging from psychoeducation in serious games or in video or written modules over training of cognitive functions to video sessions [1,2]. Smartphone usage is on the rise, allowing ambulatory assessment of mood or experience in everyday life [1,2]. Tablets are mainly used for trainings to improve attention or social and communicative skills via apps [1,2].
Most published DHI studies were conducted in the Western Hemisphere and Asia, with only few studies from South American and African countries [2]. Due to the advantages of DHI in providing treatment over extensive distances and an increasingly evolving IT-infrastructure for example in African countries, more use of DHI can be expected worldwide.

Practical aspects in using DHI
Implementing DHI in clinical practice requires careful consideration of a variety of prerequisites and precautions [3]. Table 1 gives an overview of practical prerequisites, ranging from personal aspects over data security and regional legal frameworks to the relevance of instable therapeutic situations including suicidality. DHI provide unique benefits, as proven during the SARS-CoV2-19 lock-down, but also bring potential pitfalls. Table 2 gives an overview on aspects regarding accessibility, the implementation of interventions itself, the evidence regarding interventions as well as economic aspects [4].
In summary, DHI are promising therapeutic interventions for children and adolescents with psychiatric disorders, with already robust data regarding depression and anxiety disorders. SARS-CoV2-19 catalyses the integration of DHI into the standard repertoire of child and adolescent psychiatry and psychotherapy. Nevertheless, for using DHI in daily therapeutic work there are still challenges to overcome, ranging from technical aspects, e.g. general availability of the technical prerequisites, to the most demanding therapeutic tasks like the stabilisation of patients in acute crises. Blended treatment formats using a combination of traditional face-to-face sessions with e.g. intermittent video conferences might be the silver bullet in integrating DHI and taking advantage of their strengths.
Fortunately, at least one partner in therapy, the children and adolescents, are often accustomed to and sometimes highly trained in digitally delivered communication. So, it Therapists have to be highly sensitive regarding key signals (e.g. severely depressed mood, hopelessness) Interventions in case of aggravation and safety precautions Increase of the frequency of synchronous communication e.g. via video conferencing as a tool to deliver support during vulnerable episodes At least one parent has to be present in the house during video therapy sessions Therapist needs patient's/parents' contact information at hand to be able to initiate emergency services when needed Cooperation with local professionals (paediatrician, psychiatrists) for emergency support is up to us to use our profound expertise in traditional psychotherapy to create the digital pathways for reaching out to them. Times are changing. Let's go.
Acknowledgements Open Access funding provided by Projekt DEAL.
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