Emerging Trends in The Social and Behavioral Sciences · Computer Technology and Children's Mental Health

Computer Technology and Children's Mental Health

Media

Part of Computer Technology and Children's Mental Health

Title: Computer Technology and Children's Mental Health
extracted text: Computer Technology and Children’s
Mental Health
PHILIP C. KENDALL, MATTHEW M. CARPER,
MUNIYA S. KHANNA, and M. SUE HARRIS

Abstract
Computer technology has sparked rapid change for children’s mental health, altering
how treatments can be delivered (e.g., stand-alone, computer-assisted). Research has
found that computerized approaches produce comparable outcomes as treatments
provided face-to-face. We define terms related to computer-assisted treatment and,
with a focus on anxiety in youth, we consider the outcomes of computer-based and
computer-assisted interventions (programs for youth, programs for training therapists, and programs for parents). We conclude with consideration of advances in
technology and benefits for service providers, consumers, and researchers, and a discussion of key issues.

INTRODUCTION
The rapid, if not dramatic, technological advances of the past decade will
likely be matched, if not surpassed, in the decades ahead. Today’s youth do
not know a world without cell phones or without widespread Internet access,
and many are already tapping today’s initial technological advances as part
of their pathways to mental health. “What is available currently?” What do
the current options indicate to be the emerging programs of the next decade?
Visionaries are not known for their cautious statements, and that applies to
technology and children’s mental health as well. That said, and although we
hope to offer vision, our scientific approach betrays that a dash of caution is
warranted with regard to “what works” within technology to improve children’s mental health.
Disproportionate anxiety is highly prevalent in youth and causes substantial impairment in school, family relationships, and social functioning. Left
untreated, anxiety is associated with future anxiety disorders, depression,
and substance use problems. When anxiety in youth is treated effectively,
there can be benefits in reducing subsequent sequelae (Benjamin, Harrison,
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Settipani, Brodman, & Kendall, 2013). Evidence supports the efficacy and
durability of cognitive behavioral therapy (CBT) for anxiety in youth (for
review see Hollon & Beck, 2013; Kendall, 2012). One barrier to dissemination
is the lack of a CBT-trained workforce. Computer-based (stand-alone) and
computer-assisted (in combination with face-to-face therapy) programs facilitate the delivery of CBT, and play an important role in broadening the availability of empirically supported treatments in the community.
Computers have practical advantages (e.g., accessibility) and can also
enhance therapist training. Treatment manuals are valuable for training,
but providing manuals has not yet, by itself, resulted in improved quality
practice. Computer-based training offers the potential to improve training
by including standardized therapy materials (e.g., practice examples), and
easily accessed video clips of sessions and illustrations of preferred and
nonpreferred interventions.
FOUNDATIONAL WORK
We are amidst a growing interest in, at the global level, the development of
mental health practice supported by technology and electronic communication (Myers & Turvey, 2013). In 2010, 75% of US citizens lived in families
with Internet access. As of 2011, 39 states have agreed to reimbursement for
telemedicine within their Medicaid (Center for Telehealth and e-Health Law,
2011). There are a few terms that merit clarification before we begin. Several
names have been used for different modalities of treatment involving technology, some used interchangeably. To provide clarification, we briefly define
some common terms.
Telehealth and e-health are umbrella terms used to describe delivery of
health-related services via any telecommunications and computer technology including phone, smartphone (e.g., alerts, monitoring tools), and
Internet. E-therapy, teletherapy, telemental health, or Internet-delivered therapy
typically refers to treatment being provided directly in real time by a mental
health professional through an online platform such as Skype®, Webex®,
GoToMeeting®, or other videoconferencing platforms. Internet-based treatment, or computer-based treatment, typically refers to stand-alone treatments
that are distributed and completed online or on the computer via DVD or
downloadable content. These are akin to self-help programs, where the
patient interacts with (or reads from) the program with no support, or
minimal support from a professional. There are also several computer-assisted
or Internet-assisted treatments that are programs designed to buttress
face-to-face treatment with computer-presented interactive content.
The UK National Institute for Health and Care Excellence (NICE) has
deemed computerized cognitive behavioral therapy (CCBT) an acceptable

Computer Technology and Children’s Mental Health

3

first-line treatment option for the management of depression in primary and
secondary care and for the management of anxiety (panic disorder, with or
without agoraphobia, and generalized anxiety disorder (GAD)) in adults in
primary, secondary, and community care (NICE, 2011). Importantly, data are
currently accumulating on the feasibility of computer-assisted approaches
for these conditions with children and adolescents.
ILLUSTRATIVE ADVANCES: COMPUTERS AND CHILD ANXIETY
Evidence supports computer-based and computer-assisted interventions
for adults—What has been done for children? Several efforts merit mention. Spence, Holmes, March, and Lipp (2006) delivered CBT partially
via the Internet (a group format for 7- to 14-year-olds) and reported that
the Internet-assisted program (8 of 16 sessions delivered via the Internet)
resulted in significant reductions in anxiety symptoms. March, Spence and
Donovan (2009) described BRAVE, an Internet-based treatment (minimal
therapist contact via phone/email) for anxious youth. The BRAVE-ONLINE
intervention (Spence et al., 2011) resulted in improvements in anxiety
symptoms for the 12- to 17-year-olds.
CAMP COPE-A-LOT
Camp Cope-A-Lot (CCAL; Kendall & Khanna, 2008a; see Figure 1. Sample
Images), a computer-assisted intervention for anxious children aged 7 to 13,
combines evidence-based CBT (Coping Cat program) with computer flash
animation, audio, 2D animations, photographs, videos, schematics, a built-in
reward system, self-check system, written text and a fun cartoon character,
“Charlie,” to guide the user through the program.
The user scrolls over each of the campers and then gets to read the thought
in the thought bubbles. Some thoughts are likely to increase anxiety (“Anxious Thoughts” … such as expecting bad things to happen), whereas other
thoughts (“Others”) are not. As the child reads and sorts the camper’s various thoughts, the camper’s face is used to identify the sorting.
CCAL is a “computer-assisted” treatment program—that is, it employs
minimal, but necessary involvement of an adult “coach.” Khanna and
Kendall (2010) compared CCAL to CBT and to a computer-assisted education/support/attention condition (CESA). Findings indicated that,
with regard to symptom reduction, children reached significantly greater
treatment gains from CCAL and CBT than from CESA. Also, 75%, 88%,
and 23% of principal diagnoses in CBT, CCAL, and CESA, respectively,
were no longer principal at posttreatment, and gains were maintained at
3-month follow-up. In contrast to concerns voiced about computer-based
interventions, the therapeutic relationship did not suffer: There were no

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

I NEVER
DID THIS
BEFORE.
WHAT IF I
MESS UP?

Anxious
thoughts

Others

Figure 1 Camp Cope-a-Lot sample interactivity: identifying anxious thoughts.

significant differences in the child–therapist alliance between the conditions
with a face-to-face therapist and the computer-assisted program.
An effectiveness trial (Storch and colleagues) evaluating CCAL in community mental health centers (CMHCs) found that children who received
CCAL as delivered by therapists with limited CBT experience showed significant reductions in anxiety severity and impairment (Crawford, Salloum,

Computer Technology and Children’s Mental Health

5

Lewin, Andel, Murphy, & Storch, 2014). High levels of family satisfaction
were also reported. CCAL was also found to significantly reduce symptoms
of anxiety in youth with epilepsy and anxiety disorders (Blocher, Fujikawa,
Sung, Jackson, & Jones, 2013). Preliminary studies suggest that youth with
autism spectrum disorders (ASD) may find computerized treatments inherently appealing and engaging.
CBT4CBT: COMPUTER-BASED TRAINING IN COGNITIVE-BEHAVIORAL THERAPY FOR CHILD
ANXIETY
Arguably, one of the most important components of the dissemination and
implementation of empirically supported treatments to real-world settings
is the training of the therapists. Computer-based therapist training programs
may be ideal tools. Advantages include (i) self-paced learning, (ii) increased
accessibility, (iii) cost-efficiency, (iv) standardization of training, and (v)
consistency in quality. Internet and computer-based training programs
can increase the accessibility of empirically supported procedures and can
accelerate learning.
Studies evaluating computer-based training compare computer-based
training to traditional class instruction, with tests of knowledge and ratings of student satisfaction as outcome measures. A meta-analysis (Kulik,
1994) reported a medium effect size favoring computer-based training to
traditional instruction, with students learning more in less time with the
computer-based approaches. Along with data on training effectiveness,
there is a need for research examining the impact of computer-based training
on the quality of therapy outcomes.
CBT4CBT (computer-based training in vognitive-behavioral therapy for anxious
youth; Kendall & Khanna, 2008b) is a DVD program based on CBT for
anxious children (Kendall & Hedtke, 2006) The CBT4CBT program provides
step-by-step instructions to guide the therapist and allows the user to pause
and reverse (self-paced learning), to print session materials, and to run
portions of the program in session. The program adds audiovisual examples
that aid in communicating the treatment strategies and includes built-in
trainee competency checks. An initial evaluation of CBT4CBT compared the
program to a manual and a wait list.
Knowledge significantly improved following training for both CBT4CBT
and manual-based methods, with trainees in the CBT4CBT group scoring
higher at posttraining than the manual group. Future research needs to assess
the effect of the training program on therapist behavior (competence, treatment integrity) and child outcomes.

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

CHILD ANXIETY TALES: COMPUTER-BASED PARENT-TRAINING FOR CHILD ANXIETY
Parents/guardians are often unsure of when it is time to help, or how best
to help their children, and they often turn to self-help printed materials
(bibliotherapy). However, many available resources lack empirical support.
Computer-based programs offer an accessible, equally private and convenient, but engaging resource for parents who would like to help their child
better manage anxiety. Child Anxiety Tales is a 10-module web-based program (www.copingcatparents.com) to guide parents. Preliminary findings
indicate that web-based parent training is acceptable and feasible, and that it
has the potential to enhance child outcomes and improve family functioning
(Khanna, Aschenbr, & Kendall, 2007).
EXPANDING AREAS FOR APPLICATION
As evident in our overview of work done to date, technological innovations
for children’s mental health, using youth anxiety as the exemplar, have been
developed and have been found to be useful. Although technology is being
used in a variety of ways to improve access to quality mental health care
for children and their families, few clinicians and patients know about these
types of interventions (Carper, McHugh, & Barlow, 2013). Efforts to “spread
the word” about existing programs are needed. We next consider some recent
works, organized by type of intervention, that offer additional areas for
application.
ADJUNCTS TO TREATMENT AND MOBILE TECHNOLOGY
Smartphone applications (apps) are everywhere, and the encouragement to
develop an app is reminiscent of the tip “plastics” in the film “The Graduate.”
Numerous phone apps that are available to the public are aimed at improving
the assessment and treatment of mental health concerns. These apps function in a variety of ways, including symptom assessment, psychoeducation,
resource location, and tracking of treatment progress. Used as an adjunct to
mental health services, smartphone apps allow patients access to information regarding their care at any time of day, and allow service providers to
monitor their patients’ progress in real time without retrospective recall bias.
For example, a depressed adult, when asked about a previous week, might
reply “I did not do much.” However, a daily record of activities recorded in
real time would indicate that the patient had been active. The data from the
app, not an argument with the service provider, would correct the inaccuracy
of a depressive retrospective report.
Currently, with only a few apps available for children’s mental health
needs, the majority of mental health apps are for adults. Given that 78% of

Computer Technology and Children’s Mental Health

7

American teenagers have a cell phone and half of those are smartphones,
this generation may be particularly amenable to the use of apps for mental
health care.
Apps have been developed for other uses. For example, given the importance of homework in CBT, apps aimed at increasing homework compliance
may be particularly helpful to clinicians and youth clients. Anxiety Coach
(Mayo Clinic, 2012) is an iPhone app designed to encourage clients to engage
in exposure tasks, provide support to clients during exposure tasks, provide
information about anxiety to clients, assess symptoms in real time, and provide easily accessible communication with therapists. These functions are
ultimately aimed at improving outcomes through support outside of session.
One feature of these apps that is particularly helpful and may improve our
understanding of the treatment of mental health issues among youth is a
focus on real-time assessment of symptoms. Ecological momentary assessment (EMA) is a technique that is being increasingly used in research to
collect real-time data in participants’ natural environments, allowing for the
assessment of changes over time and across situations (Shiffman, Stone, &
Hufford, 2008). Indeed, EMA has been used successfully among depressed
youth (e.g., Silk et al., 2011) to assess daily fluctuations in symptoms. Use of
EMA in clinical settings could allow clinicians to monitor between-session
changes in symptoms, which could prompt discussion with clients during
session about particular symptom triggers.
Smartphone apps represent an emerging technology for use in mental
health services and, for example, a smartphone app is being developed
for the Coping Cat program (Pramana, Parmanto, Kendall, & Silk, 2013).
But service providers often do not have the programming expertise to
develop apps specific to their needs, and hiring outside developers is often
restricted by cost. In an attempt to bridge the gap between smartphone
technology, research, and clinical care, a nonprofit organization, Open
mHealth (http://openmhealth.org), was developed to build an open software architecture to increase the sharing of data, software applications, and
study metadata (Estrin & Sim, 2010). Open mHealth is in its infancy, but
current collaborations include the US Department of Veterans Affairs on the
PTSDCoach app (discussed earlier).
STANDALONE TREATMENTS
Examples of standalone treatment programs have already been mentioned. Indeed, a recent meta-analysis of standalone treatments found that
computer-based and computer-assisted approaches demonstrated outcomes
comparable to face-to-face treatments (Andrews, Cuijpers, Craske, McEvoy,
& Titov, 2010). The computer-assisted modality offers an accessible and

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

potentially cost-effective alternative to traditional face-to-face therapy that
improves access to evidence-based care.
Computers allow for the development of skills in a highly standardized,
predictable, and controlled manner, which may be particularly beneficial
for youth with ASD, given the discomfort this population experiences with
unpredictable environments. Youth with ASD often experience comorbid
anxiety, which can be targeted with computer-assisted interventions. A
recent review of technology for improving social communication among
individuals with ASD concluded that computer technology is a promising
strategy for delivering interventions to ASD individuals (Wainer & Ingersoll,
2011). This topic is a likely focus for increased research in the coming years.
TECHNOLOGY TO EMPOWER CONSUMERS
How much more effective might health care be with continuous, real-time
data from users (i.e., patients)? Patients interacting with and contributing to
real-time health data—their own, their child’s, their parents’—so that assessments are real time, not retrospective, and continuous, not just at well-visits
and/or physicals. konciergeMD (www.konciergemd.com) is such a portal.
Patients track symptoms and treatment plans. With konciergeMD, the parent engages with the pediatrician before, during, and after the visit. As more
patients engage with the platform, the sensitivity and specificity of the tracking tools increase—leading to even more accurate diagnoses, earlier interventions, and better health outcomes—across medical conditions, and across the
lifespan, globally.
TECHNOLOGY FOR SERVICE PROVIDERS
There are numerous tools available to service providers for a variety of clinical tasks, including training and making referrals. The proliferation of these
strategies is highlighted by best practice guidelines for telepsychiatry with
children and adolescents (Myers et al., 2008), and the current development of
best practice guidelines for the remote delivery of mental health services by
Association of State and Provincial Psychology Boards’ Telepsychology Task
Force (http://tinyurl.com/d779z54).
One strategy that has gained attention in the media is the use of webcams
to deliver treatment. The advent of webcams has allowed service providers
to reach clients without the barrier of distance. Treatment-seeking clients
appear to prefer webcam-based interventions at a higher rate than alternative forms of technological interventions (Carper et al., 2013). Studies have
evaluated the efficacy of webcams for treating a wide range of problems.
However, there have been few randomized controlled trials evaluating this

Computer Technology and Children’s Mental Health

9

modality (Pesamaa, Ebeling, Kuusimaki, Winblad, Isohanni, & Moilanen,
2003; Richardson, Frueh, Grubaugh, Egede, & Elhai, 2009). A recent study of
webcam-delivered CBT for early-onset OCD found improvements in OCD
symptoms among all participants who received the intervention and high
levels of client acceptability (Comer et al., 2014). Among depressed children,
Nelson, Barnard, and Cain (2003) found improvements in depressive symptoms among participants receiving face-to-face and webcam-based CBT.
However, participants in the webcam condition demonstrated a faster rate
of decline in self-reported depressive symptoms relative to the face-to-face
condition.
Not unlike CBT4CBT, webcam technology has been used to train clinicians
in face-to-face CBT. Rees and Gillam (2001) used webcams to train service
providers in CBT and found increases in knowledge of CBT principles from
pre- to post-training. The authors also found that the majority of participants
were satisfied with the training and believed it gave them greater confidence
in their ability to use CBT with their clients. These findings offer initial support for the use of webcams in training CBT therapists.
TECHNOLOGY FOR RESEARCHERS
Technological innovations for the management and storage of data internally and across sites and for the analysis of study data have been developed
and are being used worldwide. For example, the Research Electronic Data
Capture (REDCap) Consortium (http://project-redcap.org) is a secure web
application to capture and store data for research studies. REDCap, in 2013,
was being used for more than 66,000 studies by over 85,000 researchers at 622
institutions in 55 countries. The program is available to all consortium partners and is designed to allow users to build secure surveys and databases
online to house study data.
Open-access statistical programs are proliferating, with researchers switching from expensive software to open-access alternatives such as R (www.rproject.org). The base R program functions through an object-oriented
language and offers similar tools to many commercial statistical software
programs. However, one advantage of R over commercial alternatives is that
it allows for “add-on packages” to keep current with the statistical literature.
Thus, analyses that typically would have required more expensive specialty
programs or new versions of existing programs to conduct are now available
for free. Although analyses using most of the add-on packages must be
programmed using syntax, R does have several point-and-click graphical
user interfaces (GUIs) such as R Commander (www.rcommander.com) and
RStudio (www.rstudio.org) that allow users to use basic functions in R
without learning R’s programming language. Researchers have begun using

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

R because of its open source platform and increased statistical functionality,
a trend that is likely to continue.
Another tool for researchers is being developed for dissemination and
implementation science (DIS) as a database of free instruments to improve
consistency in measurement across studies (Lewis, Krimer, Comtois, Landes,
Lyon, & Borntrager, 2011). Such a database allows researchers to quickly
see what instruments are available for measuring variables of interest.
The DIS instrument database will rate each instrument on its degree of
empirical validation, allowing researchers to quickly view psychometric
data. Such a database, if extended to include outcome instruments for use in
treatments for youth, could greatly decrease the time required by researchers
when planning projects and could improve consistency in the reporting of
outcomes from treatment trials.

KEY ISSUES FOR THE FUTURE
Technology is quickly changing the quality and methods for delivering
children’s mental health care. Smartphone apps, computer-assisted, and
web-based interventions are being developed for a variety of disorders, a
desirable trend that is likely to continue in future years. However, as technology takes on an increasing role, novel and unforeseen ethical issues are
likely to arise. There are some guidelines available to individuals interested
in incorporating technology into their practice, and guidelines have been
developed for conducting research on Internet interventions. However,
these are preliminary and likely to require frequent revision as technology
advances. It is crucial that future work identify and address the ethical
challenges that arise, revise guidelines accordingly, and quickly disseminate
them to practitioners.
Electronic medical records (EMRs) should become the standard in the years
to come, improving the quality and efficiency of large-scale epidemiological research and clinical care. For example, researchers could query EMRs
from a variety of institutions and receive deidentified data that could provide information on prevalence and incidence rates of a variety of conditions.
In addition, information could be integrated into one EMR from a variety
of providers, affording patients more comprehensive and informed care. Of
course, there may be security challenges, but these can be addressed.
The future of technology and children’s mental health will likely see an
increased number of professional organizations dedicated to this topic. Professional organizations allow service providers, researchers, and policy makers to share information with the goal of providing better care. For example,

Computer Technology and Children’s Mental Health

11

there are currently several organizations dedicated to the intersection of technology and mental health such, as the International Society for Mental Health
Online (www.ismho.org), the International Society for Research on Internet
Interventions (www.isrii.org), and the Society for Computers in Psychology
(http://www.scip.com).
The future of technology in children’s mental health will have to address
the ability of program developers and service providers to be able to adapt
and branch programs according to client needs. One way of meeting this
need is through technology interventions that include assessments capable of
identifying areas of distress and adapting intervention content to the results.
Adaptive computer-assisted interventions allow youth to access individualized mental health care.
REFERENCES
Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer
therapy for the anxiety and depressive disorders is effective, acceptable, and practical health care: A meta-analysis. PLoS ONE, 5, e13196.
Benjamin, C., Harrison, J., Settipani, C., Brodman, D., & Kendall, P. C. (2013). Anxiety
and related outcomes in young adults 7 to 19 years after receiving treatment for
child anxiety. Journal of Consulting and Clinical Psychology, 81, 865–876.
Blocher, J. B., Fujikawa, M., Sung, C., Jackson, D. C., & Jones, J. E. (2013).
Computer-assisted cognitive behavioral therapy for children with epilepsy and
anxiety: A pilot study. Epilepsy & Behavior, 27, 70–76.
Carper, M. M., McHugh, R. K., & Barlow, D. H. (2013). The dissemination of
computer-based psychological treatment: A preliminary analysis of patient and
clinician perceptions. Administration and Policy in Mental Health and Mental Health
Services Research, 40, 87–95.
Center for Telehealth and e-Health Law. (2011). Medicaid reimbursement. Retrieved
from http://www.nrel.gov/learning/re_biofuels.html
Comer, J. S., Furr, J. M., Cooper-Vince, C. E., Kerns, C. E., Chan, P. T., Edson, A. L.
… Freeman, J. B. (2014). Internet-delivered, family-based treatment for early-onset
OCD: A preliminary case series. Journal of Clinical Child and Adolescent Psychology,
43, 74–87.
Crawford, E. A., Salloum, A., Lewin, A. B., Andel, R., Murphy, T. K., & Storch, E.
A. (2014). A pilot study of computer-assisted cognitive-behavioral therapy for
childhood anxiety in community mental health centers. Journal of Cognitive Psychotherapy, 27, 221.
Estrin, D. E., & Sim, I. (2010). Open mHealth architecture: An engine for health care
innovation. Science, 330, 759–760.
Hollon, S. D., & Beck, A. T. (2013). Cognitive and cognitive-behavioral therapies.
In M. J. Lambert (Ed.), Handbook of psychotherapy and behavior change (6th ed.,
pp. 393–442). Hoboken, NJ: John Wiley & Sons, Inc.

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Kendall, P. C. (2012). Treating anxiety disorders in youth. In P. C. Kendall (Ed.), Child
and adolescent therapy: Cognitive-behavioral procedures (4th ed.). New York, NY: Guilford Press.
Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing Inc www.
WorkbookPublishing.com.
Kendall, P. C., & Khanna, M. S. (2008a). Camp Cope-A-Lot: The coping cat DVD [DVD].
Ardmore, PA: Workbook Publishing Inc. ISBN: 978-1-888805-32-1
Kendall, P. C., & Khanna, M. S. (2008b). CBT4CBT: Computer-based training to become a
cognitive-behavioral therapist [DVD]. Ardmore, PA: Workbook Publishing Inc. ISBN:
978-1-888805-34-5
Khanna, M. S., Aschenbrand, S. G., & Kendall, P. C. (2007). New Frontiers: Computer
technology in the assessment and treatment of anxious youth. Behav Therapist, 30,
22–25.
Khanna, M., & Kendall, P. C. (2010). Computer-assisted cognitive behavioral therapy
for child anxiety: Results of a randomized clinical trial. Journal of Consulting and
Clinical Psychology, 78, 737–745.
Kulik, J. A. (1994). Meta-analytic studies of findings on computer-based instruction.
In E. L. Baker & H. F. O’Neil (Eds.), Technology assessment in education and training
(pp. 9–33). Hillsdale, NJ: Lawrence Erlbaum Associates.
Lewis, C., Krimer, Y., Comtois, K., Landes, S., Lyon, A., & Borntrager, C. (2011). A
comprehensive review of dissemination and implementation science instruments. Paper
presented at the Global Implementation Conference, Washington, DC.
March, S., Spence, S. H., & Donovan, C. L. (2009). The efficacy of an internet-based
cognitive-behavioral therapy intervention for child anxiety disorders. Journal of
Pediatric Psychology, 34, 474–487.
Mayo Clinic (2012). Anxiety coach. Retrieved from https://itunes.apple.com/
us/app/anxietycoach/id565943257?mt=8
Myers, K., Cain, S., Work Group on Quality Issues, & American Academy of Child
and Adolescent Psychiatry Staff (2008). Practice parameter for telepsychiatry with
children and adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 47, 1468–1483.
Myers, K., & Turvey, C. L. (Eds.) (2013). Telemental health: Clinical, technical, and administrative foundations for evidence-based practice. Waltham, MA: Elsevier.
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care. NICE clinical guideline 113. Retrieved from
http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf
Nelson, E. L., Barnard, M., & Cain, S. (2003). Treating childhood depression over
videoconferencing. Telemedicine Journal and e-Health, 9, 49–55.
Pesamaa, L., Ebeling, H., Kuusimaki, M. L., Winblad, I., Isohanni, M., & Moilanen,
I. (2003). Videoconferencing in child and adolescent telepsychiatry: A systematic
review of the literature. Journal of Telemedicine and Telecare, 10, 197–192.

Computer Technology and Children’s Mental Health

13

Pramana, G., Parmanto, B., Kendall, P. C., & Silk, J. S. (2013). The SmartCAT: An
mHealth platform for ecological momentary intervention (EMI) in child anxiety
treatment. Telemedicine and e-Health, 20(5), 419–427.
Rees, C. S., & Gillam, D. (2001). Training in cognitive-behavioural therapy for mental
health professionals: A pilot study of videoconferencing. Journal of Telemedicine and
Telecare, 7, 300–303.
Richardson, L. K., Frueh, B. C., Grubaugh, A. L., Egede, L., & Elhai, J. D. (2009).
Current directions in videoconferencing tele-mental health research. Clinical Psychology: Science and Practice, 16, 323–338.
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual Review of Clinical Psychology, 4, 1–32.
Silk, J. S., Forbes, E. E., Whalen, D. J., Jakubcak, J. L., Thompson, W. K., Ryan, N. D.,
… , Dahl, R. E. (2011). Daily emotional dynamics in depressed youth: A cell-phone
ecological momentary assessment study. Journal of Experimental Child Psychology,
110, 241–257.
Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., &
Kenardy, J. (2011). A randomized controlled trial of online versus clinic-based CBT
for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79, 629–642.
Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood
anxiety. Journal of Consulting and Clinical Psychology, 74, 614–621.
Wainer, A. L., & Ingersoll, B. R. (2011). The use of innovative computer technology
for teaching social communication to individuals with autism spectrum disorders.
Research in Autism Spectrum Disorders, 5, 96–107.

PHILIP C. KENDALL SHORT BIOGRAPHY
Philip C. Kendall, Ph.D., ABPP is Distinguished University Professor at
Temple University. His treatment programs have been translated into dozens
of languages and he has had 30 years of uninterrupted grant support. He is
among the most “Highly-Cited” individuals in the social/medical sciences
and placed fifth in a quantitative analysis of the citations to the faculty in
psychology in the United States. A Fellow at the Center for Advanced Study
in the Behavioral Sciences and award winner (e.g., Research Recognition
Award from the Anxiety Disorders Association of America; “Great Teacher”
award from Temple University; “Outstanding Contribution in Training”
from ABCT), his contributions include developing the Coping Cat program
for the treatment of anxiety disorders in youth.
MATTHEW M. CARPER SHORT BIOGRAPHY
Matthew M. Carper is a doctoral student in clinical psychology at the
Child and Adolescent Anxiety Disorders Clinic at Temple University. He

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

received his undergraduate degree in Psychology from Boston University,
where he wrote his honors thesis on barriers to the dissemination of computerized therapy. His research interests include computerized treatment
and assessment, and barriers to the dissemination and implementation
of evidence-based treatments. He is also interested in research aimed at
understanding patient, clinician, interpersonal, and intervention-specific
factors that contribute to positive clinical outcomes and the use of novel
statistical methods to examine these dynamic processes.
MUNIYA S. KHANNA SHORT BIOGRAPHY
Muniya S. Khanna is a licensed clinical psychologist at the Children’s and
Adult Center for OCD, specializing in the cognitive behavioral treatment of
childhood anxiety disorders and obsessive compulsive disorder (OCD), as
well as OC spectrum disorders including tic disorders and trichotillomania.
Dr. Khanna has served as Assistant Professor of Psychiatry and Clinical
Director of the Child and Adolescent OCD, Tic, Trich, and Anxiety Group
in the University Of Pennsylvania School Of Medicine. She is author of
numerous research articles and chapters, and co-author with Dr. Philip
Kendall of: The CAT Project, a therapist manual for the cognitive behavioral
treatment of anxious adolescents, Camp Cope-A-Lot, the first empirically
supported computer-based treatment for anxious youth, and CBT4CBT:
Computer-based training in cognitive behavioral therapy for anxious youth,
a computer-based training program for professionals interested in becoming
proficient in CBT for childhood anxiety disorders, and Child Anxiety Tales, a
web-based training program for parents of anxious youth.
Among her professional activities, she is active on the boards of APA
Division 53 and ABCT as well as national and international scientific review
boards and editorial boards. Dr. Khanna completed her doctoral degree
at Temple University, clinical internship at UCLA, and NIH-sponsored
fellowship at Columbia University.
M. SUE HARRIS SHORT BIOGRAPHY
M. Sue Harris PhD’s initial graduate work was in psychology, but her doctoral degree is in American Studies. Her first book, about post-depression
American art, was entitled “Rethinking regionalism.” She maintained an
interest in psychology and eventually started Workbook Publishing, Inc., a
company dedicated to the mission of bringing well-researched, empirically
supported, and practical books, software, and audiovisual programs to
mental health professionals, school counselors, research professionals, or
those seeking information and programs to help youth with emotional,

Computer Technology and Children’s Mental Health

15

cognitive, and behavioral problems. To date, the company focus has been on
helping youth.
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Aggression and Victimization (Psychology), Sheri Bauman and Aryn Taylor
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
Emerging Evidence of Addiction in Problematic Eating Behavior (Psychology), Ashley Gearhardt et al.
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Family Relationships and Development (Psychology), Joan E. Grusec
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
The Psychological Impacts of Cyberlife Engagement (Psychology), Virginia S.
Y. Kwan and Jessica E. Bodford
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes

16

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.; Computer Technology and Children’s
Mental Health
PHILIP C. KENDALL, MATTHEW M. CARPER,
MUNIYA S. KHANNA, and M. SUE HARRIS

Abstract
Computer technology has sparked rapid change for children’s mental health, altering
how treatments can be delivered (e.g., stand-alone, computer-assisted). Research has
found that computerized approaches produce comparable outcomes as treatments
provided face-to-face. We define terms related to computer-assisted treatment and,
with a focus on anxiety in youth, we consider the outcomes of computer-based and
computer-assisted interventions (programs for youth, programs for training therapists, and programs for parents). We conclude with consideration of advances in
technology and benefits for service providers, consumers, and researchers, and a discussion of key issues.

INTRODUCTION
The rapid, if not dramatic, technological advances of the past decade will
likely be matched, if not surpassed, in the decades ahead. Today’s youth do
not know a world without cell phones or without widespread Internet access,
and many are already tapping today’s initial technological advances as part
of their pathways to mental health. “What is available currently?” What do
the current options indicate to be the emerging programs of the next decade?
Visionaries are not known for their cautious statements, and that applies to
technology and children’s mental health as well. That said, and although we
hope to offer vision, our scientific approach betrays that a dash of caution is
warranted with regard to “what works” within technology to improve children’s mental health.
Disproportionate anxiety is highly prevalent in youth and causes substantial impairment in school, family relationships, and social functioning. Left
untreated, anxiety is associated with future anxiety disorders, depression,
and substance use problems. When anxiety in youth is treated effectively,
there can be benefits in reducing subsequent sequelae (Benjamin, Harrison,
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Settipani, Brodman, & Kendall, 2013). Evidence supports the efficacy and
durability of cognitive behavioral therapy (CBT) for anxiety in youth (for
review see Hollon & Beck, 2013; Kendall, 2012). One barrier to dissemination
is the lack of a CBT-trained workforce. Computer-based (stand-alone) and
computer-assisted (in combination with face-to-face therapy) programs facilitate the delivery of CBT, and play an important role in broadening the availability of empirically supported treatments in the community.
Computers have practical advantages (e.g., accessibility) and can also
enhance therapist training. Treatment manuals are valuable for training,
but providing manuals has not yet, by itself, resulted in improved quality
practice. Computer-based training offers the potential to improve training
by including standardized therapy materials (e.g., practice examples), and
easily accessed video clips of sessions and illustrations of preferred and
nonpreferred interventions.
FOUNDATIONAL WORK
We are amidst a growing interest in, at the global level, the development of
mental health practice supported by technology and electronic communication (Myers & Turvey, 2013). In 2010, 75% of US citizens lived in families
with Internet access. As of 2011, 39 states have agreed to reimbursement for
telemedicine within their Medicaid (Center for Telehealth and e-Health Law,
2011). There are a few terms that merit clarification before we begin. Several
names have been used for different modalities of treatment involving technology, some used interchangeably. To provide clarification, we briefly define
some common terms.
Telehealth and e-health are umbrella terms used to describe delivery of
health-related services via any telecommunications and computer technology including phone, smartphone (e.g., alerts, monitoring tools), and
Internet. E-therapy, teletherapy, telemental health, or Internet-delivered therapy
typically refers to treatment being provided directly in real time by a mental
health professional through an online platform such as Skype®, Webex®,
GoToMeeting®, or other videoconferencing platforms. Internet-based treatment, or computer-based treatment, typically refers to stand-alone treatments
that are distributed and completed online or on the computer via DVD or
downloadable content. These are akin to self-help programs, where the
patient interacts with (or reads from) the program with no support, or
minimal support from a professional. There are also several computer-assisted
or Internet-assisted treatments that are programs designed to buttress
face-to-face treatment with computer-presented interactive content.
The UK National Institute for Health and Care Excellence (NICE) has
deemed computerized cognitive behavioral therapy (CCBT) an acceptable

Computer Technology and Children’s Mental Health

3

first-line treatment option for the management of depression in primary and
secondary care and for the management of anxiety (panic disorder, with or
without agoraphobia, and generalized anxiety disorder (GAD)) in adults in
primary, secondary, and community care (NICE, 2011). Importantly, data are
currently accumulating on the feasibility of computer-assisted approaches
for these conditions with children and adolescents.
ILLUSTRATIVE ADVANCES: COMPUTERS AND CHILD ANXIETY
Evidence supports computer-based and computer-assisted interventions
for adults—What has been done for children? Several efforts merit mention. Spence, Holmes, March, and Lipp (2006) delivered CBT partially
via the Internet (a group format for 7- to 14-year-olds) and reported that
the Internet-assisted program (8 of 16 sessions delivered via the Internet)
resulted in significant reductions in anxiety symptoms. March, Spence and
Donovan (2009) described BRAVE, an Internet-based treatment (minimal
therapist contact via phone/email) for anxious youth. The BRAVE-ONLINE
intervention (Spence et al., 2011) resulted in improvements in anxiety
symptoms for the 12- to 17-year-olds.
CAMP COPE-A-LOT
Camp Cope-A-Lot (CCAL; Kendall & Khanna, 2008a; see Figure 1. Sample
Images), a computer-assisted intervention for anxious children aged 7 to 13,
combines evidence-based CBT (Coping Cat program) with computer flash
animation, audio, 2D animations, photographs, videos, schematics, a built-in
reward system, self-check system, written text and a fun cartoon character,
“Charlie,” to guide the user through the program.
The user scrolls over each of the campers and then gets to read the thought
in the thought bubbles. Some thoughts are likely to increase anxiety (“Anxious Thoughts” … such as expecting bad things to happen), whereas other
thoughts (“Others”) are not. As the child reads and sorts the camper’s various thoughts, the camper’s face is used to identify the sorting.
CCAL is a “computer-assisted” treatment program—that is, it employs
minimal, but necessary involvement of an adult “coach.” Khanna and
Kendall (2010) compared CCAL to CBT and to a computer-assisted education/support/attention condition (CESA). Findings indicated that,
with regard to symptom reduction, children reached significantly greater
treatment gains from CCAL and CBT than from CESA. Also, 75%, 88%,
and 23% of principal diagnoses in CBT, CCAL, and CESA, respectively,
were no longer principal at posttreatment, and gains were maintained at
3-month follow-up. In contrast to concerns voiced about computer-based
interventions, the therapeutic relationship did not suffer: There were no

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

I NEVER
DID THIS
BEFORE.
WHAT IF I
MESS UP?

Anxious
thoughts

Others

Figure 1 Camp Cope-a-Lot sample interactivity: identifying anxious thoughts.

significant differences in the child–therapist alliance between the conditions
with a face-to-face therapist and the computer-assisted program.
An effectiveness trial (Storch and colleagues) evaluating CCAL in community mental health centers (CMHCs) found that children who received
CCAL as delivered by therapists with limited CBT experience showed significant reductions in anxiety severity and impairment (Crawford, Salloum,

Computer Technology and Children’s Mental Health

5

Lewin, Andel, Murphy, & Storch, 2014). High levels of family satisfaction
were also reported. CCAL was also found to significantly reduce symptoms
of anxiety in youth with epilepsy and anxiety disorders (Blocher, Fujikawa,
Sung, Jackson, & Jones, 2013). Preliminary studies suggest that youth with
autism spectrum disorders (ASD) may find computerized treatments inherently appealing and engaging.
CBT4CBT: COMPUTER-BASED TRAINING IN COGNITIVE-BEHAVIORAL THERAPY FOR CHILD
ANXIETY
Arguably, one of the most important components of the dissemination and
implementation of empirically supported treatments to real-world settings
is the training of the therapists. Computer-based therapist training programs
may be ideal tools. Advantages include (i) self-paced learning, (ii) increased
accessibility, (iii) cost-efficiency, (iv) standardization of training, and (v)
consistency in quality. Internet and computer-based training programs
can increase the accessibility of empirically supported procedures and can
accelerate learning.
Studies evaluating computer-based training compare computer-based
training to traditional class instruction, with tests of knowledge and ratings of student satisfaction as outcome measures. A meta-analysis (Kulik,
1994) reported a medium effect size favoring computer-based training to
traditional instruction, with students learning more in less time with the
computer-based approaches. Along with data on training effectiveness,
there is a need for research examining the impact of computer-based training
on the quality of therapy outcomes.
CBT4CBT (computer-based training in vognitive-behavioral therapy for anxious
youth; Kendall & Khanna, 2008b) is a DVD program based on CBT for
anxious children (Kendall & Hedtke, 2006) The CBT4CBT program provides
step-by-step instructions to guide the therapist and allows the user to pause
and reverse (self-paced learning), to print session materials, and to run
portions of the program in session. The program adds audiovisual examples
that aid in communicating the treatment strategies and includes built-in
trainee competency checks. An initial evaluation of CBT4CBT compared the
program to a manual and a wait list.
Knowledge significantly improved following training for both CBT4CBT
and manual-based methods, with trainees in the CBT4CBT group scoring
higher at posttraining than the manual group. Future research needs to assess
the effect of the training program on therapist behavior (competence, treatment integrity) and child outcomes.

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

CHILD ANXIETY TALES: COMPUTER-BASED PARENT-TRAINING FOR CHILD ANXIETY
Parents/guardians are often unsure of when it is time to help, or how best
to help their children, and they often turn to self-help printed materials
(bibliotherapy). However, many available resources lack empirical support.
Computer-based programs offer an accessible, equally private and convenient, but engaging resource for parents who would like to help their child
better manage anxiety. Child Anxiety Tales is a 10-module web-based program (www.copingcatparents.com) to guide parents. Preliminary findings
indicate that web-based parent training is acceptable and feasible, and that it
has the potential to enhance child outcomes and improve family functioning
(Khanna, Aschenbr, & Kendall, 2007).
EXPANDING AREAS FOR APPLICATION
As evident in our overview of work done to date, technological innovations
for children’s mental health, using youth anxiety as the exemplar, have been
developed and have been found to be useful. Although technology is being
used in a variety of ways to improve access to quality mental health care
for children and their families, few clinicians and patients know about these
types of interventions (Carper, McHugh, & Barlow, 2013). Efforts to “spread
the word” about existing programs are needed. We next consider some recent
works, organized by type of intervention, that offer additional areas for
application.
ADJUNCTS TO TREATMENT AND MOBILE TECHNOLOGY
Smartphone applications (apps) are everywhere, and the encouragement to
develop an app is reminiscent of the tip “plastics” in the film “The Graduate.”
Numerous phone apps that are available to the public are aimed at improving
the assessment and treatment of mental health concerns. These apps function in a variety of ways, including symptom assessment, psychoeducation,
resource location, and tracking of treatment progress. Used as an adjunct to
mental health services, smartphone apps allow patients access to information regarding their care at any time of day, and allow service providers to
monitor their patients’ progress in real time without retrospective recall bias.
For example, a depressed adult, when asked about a previous week, might
reply “I did not do much.” However, a daily record of activities recorded in
real time would indicate that the patient had been active. The data from the
app, not an argument with the service provider, would correct the inaccuracy
of a depressive retrospective report.
Currently, with only a few apps available for children’s mental health
needs, the majority of mental health apps are for adults. Given that 78% of

Computer Technology and Children’s Mental Health

7

American teenagers have a cell phone and half of those are smartphones,
this generation may be particularly amenable to the use of apps for mental
health care.
Apps have been developed for other uses. For example, given the importance of homework in CBT, apps aimed at increasing homework compliance
may be particularly helpful to clinicians and youth clients. Anxiety Coach
(Mayo Clinic, 2012) is an iPhone app designed to encourage clients to engage
in exposure tasks, provide support to clients during exposure tasks, provide
information about anxiety to clients, assess symptoms in real time, and provide easily accessible communication with therapists. These functions are
ultimately aimed at improving outcomes through support outside of session.
One feature of these apps that is particularly helpful and may improve our
understanding of the treatment of mental health issues among youth is a
focus on real-time assessment of symptoms. Ecological momentary assessment (EMA) is a technique that is being increasingly used in research to
collect real-time data in participants’ natural environments, allowing for the
assessment of changes over time and across situations (Shiffman, Stone, &
Hufford, 2008). Indeed, EMA has been used successfully among depressed
youth (e.g., Silk et al., 2011) to assess daily fluctuations in symptoms. Use of
EMA in clinical settings could allow clinicians to monitor between-session
changes in symptoms, which could prompt discussion with clients during
session about particular symptom triggers.
Smartphone apps represent an emerging technology for use in mental
health services and, for example, a smartphone app is being developed
for the Coping Cat program (Pramana, Parmanto, Kendall, & Silk, 2013).
But service providers often do not have the programming expertise to
develop apps specific to their needs, and hiring outside developers is often
restricted by cost. In an attempt to bridge the gap between smartphone
technology, research, and clinical care, a nonprofit organization, Open
mHealth (http://openmhealth.org), was developed to build an open software architecture to increase the sharing of data, software applications, and
study metadata (Estrin & Sim, 2010). Open mHealth is in its infancy, but
current collaborations include the US Department of Veterans Affairs on the
PTSDCoach app (discussed earlier).
STANDALONE TREATMENTS
Examples of standalone treatment programs have already been mentioned. Indeed, a recent meta-analysis of standalone treatments found that
computer-based and computer-assisted approaches demonstrated outcomes
comparable to face-to-face treatments (Andrews, Cuijpers, Craske, McEvoy,
& Titov, 2010). The computer-assisted modality offers an accessible and

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

potentially cost-effective alternative to traditional face-to-face therapy that
improves access to evidence-based care.
Computers allow for the development of skills in a highly standardized,
predictable, and controlled manner, which may be particularly beneficial
for youth with ASD, given the discomfort this population experiences with
unpredictable environments. Youth with ASD often experience comorbid
anxiety, which can be targeted with computer-assisted interventions. A
recent review of technology for improving social communication among
individuals with ASD concluded that computer technology is a promising
strategy for delivering interventions to ASD individuals (Wainer & Ingersoll,
2011). This topic is a likely focus for increased research in the coming years.
TECHNOLOGY TO EMPOWER CONSUMERS
How much more effective might health care be with continuous, real-time
data from users (i.e., patients)? Patients interacting with and contributing to
real-time health data—their own, their child’s, their parents’—so that assessments are real time, not retrospective, and continuous, not just at well-visits
and/or physicals. konciergeMD (www.konciergemd.com) is such a portal.
Patients track symptoms and treatment plans. With konciergeMD, the parent engages with the pediatrician before, during, and after the visit. As more
patients engage with the platform, the sensitivity and specificity of the tracking tools increase—leading to even more accurate diagnoses, earlier interventions, and better health outcomes—across medical conditions, and across the
lifespan, globally.
TECHNOLOGY FOR SERVICE PROVIDERS
There are numerous tools available to service providers for a variety of clinical tasks, including training and making referrals. The proliferation of these
strategies is highlighted by best practice guidelines for telepsychiatry with
children and adolescents (Myers et al., 2008), and the current development of
best practice guidelines for the remote delivery of mental health services by
Association of State and Provincial Psychology Boards’ Telepsychology Task
Force (http://tinyurl.com/d779z54).
One strategy that has gained attention in the media is the use of webcams
to deliver treatment. The advent of webcams has allowed service providers
to reach clients without the barrier of distance. Treatment-seeking clients
appear to prefer webcam-based interventions at a higher rate than alternative forms of technological interventions (Carper et al., 2013). Studies have
evaluated the efficacy of webcams for treating a wide range of problems.
However, there have been few randomized controlled trials evaluating this

Computer Technology and Children’s Mental Health

9

modality (Pesamaa, Ebeling, Kuusimaki, Winblad, Isohanni, & Moilanen,
2003; Richardson, Frueh, Grubaugh, Egede, & Elhai, 2009). A recent study of
webcam-delivered CBT for early-onset OCD found improvements in OCD
symptoms among all participants who received the intervention and high
levels of client acceptability (Comer et al., 2014). Among depressed children,
Nelson, Barnard, and Cain (2003) found improvements in depressive symptoms among participants receiving face-to-face and webcam-based CBT.
However, participants in the webcam condition demonstrated a faster rate
of decline in self-reported depressive symptoms relative to the face-to-face
condition.
Not unlike CBT4CBT, webcam technology has been used to train clinicians
in face-to-face CBT. Rees and Gillam (2001) used webcams to train service
providers in CBT and found increases in knowledge of CBT principles from
pre- to post-training. The authors also found that the majority of participants
were satisfied with the training and believed it gave them greater confidence
in their ability to use CBT with their clients. These findings offer initial support for the use of webcams in training CBT therapists.
TECHNOLOGY FOR RESEARCHERS
Technological innovations for the management and storage of data internally and across sites and for the analysis of study data have been developed
and are being used worldwide. For example, the Research Electronic Data
Capture (REDCap) Consortium (http://project-redcap.org) is a secure web
application to capture and store data for research studies. REDCap, in 2013,
was being used for more than 66,000 studies by over 85,000 researchers at 622
institutions in 55 countries. The program is available to all consortium partners and is designed to allow users to build secure surveys and databases
online to house study data.
Open-access statistical programs are proliferating, with researchers switching from expensive software to open-access alternatives such as R (www.rproject.org). The base R program functions through an object-oriented
language and offers similar tools to many commercial statistical software
programs. However, one advantage of R over commercial alternatives is that
it allows for “add-on packages” to keep current with the statistical literature.
Thus, analyses that typically would have required more expensive specialty
programs or new versions of existing programs to conduct are now available
for free. Although analyses using most of the add-on packages must be
programmed using syntax, R does have several point-and-click graphical
user interfaces (GUIs) such as R Commander (www.rcommander.com) and
RStudio (www.rstudio.org) that allow users to use basic functions in R
without learning R’s programming language. Researchers have begun using

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

R because of its open source platform and increased statistical functionality,
a trend that is likely to continue.
Another tool for researchers is being developed for dissemination and
implementation science (DIS) as a database of free instruments to improve
consistency in measurement across studies (Lewis, Krimer, Comtois, Landes,
Lyon, & Borntrager, 2011). Such a database allows researchers to quickly
see what instruments are available for measuring variables of interest.
The DIS instrument database will rate each instrument on its degree of
empirical validation, allowing researchers to quickly view psychometric
data. Such a database, if extended to include outcome instruments for use in
treatments for youth, could greatly decrease the time required by researchers
when planning projects and could improve consistency in the reporting of
outcomes from treatment trials.

KEY ISSUES FOR THE FUTURE
Technology is quickly changing the quality and methods for delivering
children’s mental health care. Smartphone apps, computer-assisted, and
web-based interventions are being developed for a variety of disorders, a
desirable trend that is likely to continue in future years. However, as technology takes on an increasing role, novel and unforeseen ethical issues are
likely to arise. There are some guidelines available to individuals interested
in incorporating technology into their practice, and guidelines have been
developed for conducting research on Internet interventions. However,
these are preliminary and likely to require frequent revision as technology
advances. It is crucial that future work identify and address the ethical
challenges that arise, revise guidelines accordingly, and quickly disseminate
them to practitioners.
Electronic medical records (EMRs) should become the standard in the years
to come, improving the quality and efficiency of large-scale epidemiological research and clinical care. For example, researchers could query EMRs
from a variety of institutions and receive deidentified data that could provide information on prevalence and incidence rates of a variety of conditions.
In addition, information could be integrated into one EMR from a variety
of providers, affording patients more comprehensive and informed care. Of
course, there may be security challenges, but these can be addressed.
The future of technology and children’s mental health will likely see an
increased number of professional organizations dedicated to this topic. Professional organizations allow service providers, researchers, and policy makers to share information with the goal of providing better care. For example,

Computer Technology and Children’s Mental Health

11

there are currently several organizations dedicated to the intersection of technology and mental health such, as the International Society for Mental Health
Online (www.ismho.org), the International Society for Research on Internet
Interventions (www.isrii.org), and the Society for Computers in Psychology
(http://www.scip.com).
The future of technology in children’s mental health will have to address
the ability of program developers and service providers to be able to adapt
and branch programs according to client needs. One way of meeting this
need is through technology interventions that include assessments capable of
identifying areas of distress and adapting intervention content to the results.
Adaptive computer-assisted interventions allow youth to access individualized mental health care.
REFERENCES
Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer
therapy for the anxiety and depressive disorders is effective, acceptable, and practical health care: A meta-analysis. PLoS ONE, 5, e13196.
Benjamin, C., Harrison, J., Settipani, C., Brodman, D., & Kendall, P. C. (2013). Anxiety
and related outcomes in young adults 7 to 19 years after receiving treatment for
child anxiety. Journal of Consulting and Clinical Psychology, 81, 865–876.
Blocher, J. B., Fujikawa, M., Sung, C., Jackson, D. C., & Jones, J. E. (2013).
Computer-assisted cognitive behavioral therapy for children with epilepsy and
anxiety: A pilot study. Epilepsy & Behavior, 27, 70–76.
Carper, M. M., McHugh, R. K., & Barlow, D. H. (2013). The dissemination of
computer-based psychological treatment: A preliminary analysis of patient and
clinician perceptions. Administration and Policy in Mental Health and Mental Health
Services Research, 40, 87–95.
Center for Telehealth and e-Health Law. (2011). Medicaid reimbursement. Retrieved
from http://www.nrel.gov/learning/re_biofuels.html
Comer, J. S., Furr, J. M., Cooper-Vince, C. E., Kerns, C. E., Chan, P. T., Edson, A. L.
… Freeman, J. B. (2014). Internet-delivered, family-based treatment for early-onset
OCD: A preliminary case series. Journal of Clinical Child and Adolescent Psychology,
43, 74–87.
Crawford, E. A., Salloum, A., Lewin, A. B., Andel, R., Murphy, T. K., & Storch, E.
A. (2014). A pilot study of computer-assisted cognitive-behavioral therapy for
childhood anxiety in community mental health centers. Journal of Cognitive Psychotherapy, 27, 221.
Estrin, D. E., & Sim, I. (2010). Open mHealth architecture: An engine for health care
innovation. Science, 330, 759–760.
Hollon, S. D., & Beck, A. T. (2013). Cognitive and cognitive-behavioral therapies.
In M. J. Lambert (Ed.), Handbook of psychotherapy and behavior change (6th ed.,
pp. 393–442). Hoboken, NJ: John Wiley & Sons, Inc.

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Kendall, P. C. (2012). Treating anxiety disorders in youth. In P. C. Kendall (Ed.), Child
and adolescent therapy: Cognitive-behavioral procedures (4th ed.). New York, NY: Guilford Press.
Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing Inc www.
WorkbookPublishing.com.
Kendall, P. C., & Khanna, M. S. (2008a). Camp Cope-A-Lot: The coping cat DVD [DVD].
Ardmore, PA: Workbook Publishing Inc. ISBN: 978-1-888805-32-1
Kendall, P. C., & Khanna, M. S. (2008b). CBT4CBT: Computer-based training to become a
cognitive-behavioral therapist [DVD]. Ardmore, PA: Workbook Publishing Inc. ISBN:
978-1-888805-34-5
Khanna, M. S., Aschenbrand, S. G., & Kendall, P. C. (2007). New Frontiers: Computer
technology in the assessment and treatment of anxious youth. Behav Therapist, 30,
22–25.
Khanna, M., & Kendall, P. C. (2010). Computer-assisted cognitive behavioral therapy
for child anxiety: Results of a randomized clinical trial. Journal of Consulting and
Clinical Psychology, 78, 737–745.
Kulik, J. A. (1994). Meta-analytic studies of findings on computer-based instruction.
In E. L. Baker & H. F. O’Neil (Eds.), Technology assessment in education and training
(pp. 9–33). Hillsdale, NJ: Lawrence Erlbaum Associates.
Lewis, C., Krimer, Y., Comtois, K., Landes, S., Lyon, A., & Borntrager, C. (2011). A
comprehensive review of dissemination and implementation science instruments. Paper
presented at the Global Implementation Conference, Washington, DC.
March, S., Spence, S. H., & Donovan, C. L. (2009). The efficacy of an internet-based
cognitive-behavioral therapy intervention for child anxiety disorders. Journal of
Pediatric Psychology, 34, 474–487.
Mayo Clinic (2012). Anxiety coach. Retrieved from https://itunes.apple.com/
us/app/anxietycoach/id565943257?mt=8
Myers, K., Cain, S., Work Group on Quality Issues, & American Academy of Child
and Adolescent Psychiatry Staff (2008). Practice parameter for telepsychiatry with
children and adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 47, 1468–1483.
Myers, K., & Turvey, C. L. (Eds.) (2013). Telemental health: Clinical, technical, and administrative foundations for evidence-based practice. Waltham, MA: Elsevier.
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care. NICE clinical guideline 113. Retrieved from
http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf
Nelson, E. L., Barnard, M., & Cain, S. (2003). Treating childhood depression over
videoconferencing. Telemedicine Journal and e-Health, 9, 49–55.
Pesamaa, L., Ebeling, H., Kuusimaki, M. L., Winblad, I., Isohanni, M., & Moilanen,
I. (2003). Videoconferencing in child and adolescent telepsychiatry: A systematic
review of the literature. Journal of Telemedicine and Telecare, 10, 197–192.

Computer Technology and Children’s Mental Health

13

Pramana, G., Parmanto, B., Kendall, P. C., & Silk, J. S. (2013). The SmartCAT: An
mHealth platform for ecological momentary intervention (EMI) in child anxiety
treatment. Telemedicine and e-Health, 20(5), 419–427.
Rees, C. S., & Gillam, D. (2001). Training in cognitive-behavioural therapy for mental
health professionals: A pilot study of videoconferencing. Journal of Telemedicine and
Telecare, 7, 300–303.
Richardson, L. K., Frueh, B. C., Grubaugh, A. L., Egede, L., & Elhai, J. D. (2009).
Current directions in videoconferencing tele-mental health research. Clinical Psychology: Science and Practice, 16, 323–338.
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual Review of Clinical Psychology, 4, 1–32.
Silk, J. S., Forbes, E. E., Whalen, D. J., Jakubcak, J. L., Thompson, W. K., Ryan, N. D.,
… , Dahl, R. E. (2011). Daily emotional dynamics in depressed youth: A cell-phone
ecological momentary assessment study. Journal of Experimental Child Psychology,
110, 241–257.
Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., &
Kenardy, J. (2011). A randomized controlled trial of online versus clinic-based CBT
for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79, 629–642.
Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood
anxiety. Journal of Consulting and Clinical Psychology, 74, 614–621.
Wainer, A. L., & Ingersoll, B. R. (2011). The use of innovative computer technology
for teaching social communication to individuals with autism spectrum disorders.
Research in Autism Spectrum Disorders, 5, 96–107.

PHILIP C. KENDALL SHORT BIOGRAPHY
Philip C. Kendall, Ph.D., ABPP is Distinguished University Professor at
Temple University. His treatment programs have been translated into dozens
of languages and he has had 30 years of uninterrupted grant support. He is
among the most “Highly-Cited” individuals in the social/medical sciences
and placed fifth in a quantitative analysis of the citations to the faculty in
psychology in the United States. A Fellow at the Center for Advanced Study
in the Behavioral Sciences and award winner (e.g., Research Recognition
Award from the Anxiety Disorders Association of America; “Great Teacher”
award from Temple University; “Outstanding Contribution in Training”
from ABCT), his contributions include developing the Coping Cat program
for the treatment of anxiety disorders in youth.
MATTHEW M. CARPER SHORT BIOGRAPHY
Matthew M. Carper is a doctoral student in clinical psychology at the
Child and Adolescent Anxiety Disorders Clinic at Temple University. He

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

received his undergraduate degree in Psychology from Boston University,
where he wrote his honors thesis on barriers to the dissemination of computerized therapy. His research interests include computerized treatment
and assessment, and barriers to the dissemination and implementation
of evidence-based treatments. He is also interested in research aimed at
understanding patient, clinician, interpersonal, and intervention-specific
factors that contribute to positive clinical outcomes and the use of novel
statistical methods to examine these dynamic processes.
MUNIYA S. KHANNA SHORT BIOGRAPHY
Muniya S. Khanna is a licensed clinical psychologist at the Children’s and
Adult Center for OCD, specializing in the cognitive behavioral treatment of
childhood anxiety disorders and obsessive compulsive disorder (OCD), as
well as OC spectrum disorders including tic disorders and trichotillomania.
Dr. Khanna has served as Assistant Professor of Psychiatry and Clinical
Director of the Child and Adolescent OCD, Tic, Trich, and Anxiety Group
in the University Of Pennsylvania School Of Medicine. She is author of
numerous research articles and chapters, and co-author with Dr. Philip
Kendall of: The CAT Project, a therapist manual for the cognitive behavioral
treatment of anxious adolescents, Camp Cope-A-Lot, the first empirically
supported computer-based treatment for anxious youth, and CBT4CBT:
Computer-based training in cognitive behavioral therapy for anxious youth,
a computer-based training program for professionals interested in becoming
proficient in CBT for childhood anxiety disorders, and Child Anxiety Tales, a
web-based training program for parents of anxious youth.
Among her professional activities, she is active on the boards of APA
Division 53 and ABCT as well as national and international scientific review
boards and editorial boards. Dr. Khanna completed her doctoral degree
at Temple University, clinical internship at UCLA, and NIH-sponsored
fellowship at Columbia University.
M. SUE HARRIS SHORT BIOGRAPHY
M. Sue Harris PhD’s initial graduate work was in psychology, but her doctoral degree is in American Studies. Her first book, about post-depression
American art, was entitled “Rethinking regionalism.” She maintained an
interest in psychology and eventually started Workbook Publishing, Inc., a
company dedicated to the mission of bringing well-researched, empirically
supported, and practical books, software, and audiovisual programs to
mental health professionals, school counselors, research professionals, or
those seeking information and programs to help youth with emotional,

Computer Technology and Children’s Mental Health

15

cognitive, and behavioral problems. To date, the company focus has been on
helping youth.
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Aggression and Victimization (Psychology), Sheri Bauman and Aryn Taylor
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
Emerging Evidence of Addiction in Problematic Eating Behavior (Psychology), Ashley Gearhardt et al.
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Family Relationships and Development (Psychology), Joan E. Grusec
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
The Psychological Impacts of Cyberlife Engagement (Psychology), Virginia S.
Y. Kwan and Jessica E. Bodford
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes

16

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.