Practical Apps 15: Child & Adolescent Anxiety

author

Dr. Niraj Mistry
Toronto, Ontario

Bio

Niraj is a practicing pediatrician in Toronto. He completed an MD at the University of Toronto and Pediatrics residency at the Hospital for Sick Children (SickKids). During his fellowship in Academic General Pediatrics he completed a Masters in eHealth (Health Informatics) at McMaster University. Niraj is currently a staff pediatrician at SickKids, St. Michael’s Hospital, Toronto Western Hospital and Scarborough Centenary. Niraj is currently focused on the user-centred design, development and implementation of novel technologies to improve the application of the best available evidence at the point of care, to enhance care delivery and optimize the patient and family experience.

Apps Reviewed:

Patient Experiences

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Anxiety Coach by Mayo Clinic

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Editor’s note: Anxiety Coach was reviewed for adult anxiety on December 19, 2017 by Dr. Matthew Cruickshank.

Anxiety Coach is an amazing anxiety self-management app. It is thoughtfully designed based on a review of existing mobile apps for childhood anxiety by clinical psychologist Dr. Stephen Whiteside (Mayo Clinic) [3]. This app has multiple strengths. There is an extensive list of common fears including child and adolescent-specific anxiety (e.g. social, separation and specific phobias) and accompanying exposure hierarchies. The exposure-based CBT treatment approach is consistent with the literature [4]. The app provides detailed step-by-step instructions on how to prepare and conduct each exposure activity in the real world. The Mayo Clinic is a reliable cutting-edge U.S.-based organization. I would highly recommend this app to any patient with anxiety, especially if they are intrinsically motivated to address their anxieties. The only criticism of this app is it is fairly text heavy and could benefit from more multimedia and interactivity. This app is like having a psychologist in your pocket!

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Features
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This app has three core sections. The psychoeducation (Learn) section provides a clear conceptualization of anxiety, different anxiety disorders and exposure-based CBT. It contains a very useful user manual for the app and advice on finding a therapist.

In the Checkup section users complete a self-test to measure and track their overall anxiety and disorder-specific anxiety symptoms over time and view them in simple progress charts. There are no reminders for users to self-test or rate their anxiety. Users can create a customized list of exposure activities by selecting from a recommended graduated list of exposure activities or adding their own activity. When completing an exposure activity, users are prompted to plan appropriately, rate the probability that “something bad will happen” and track their anxiety before, during and after the activity. There is a list of Admin Actions that seems to allow you to sync the app with a patient portal, but it is not clear.

Effectiveness
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This app addresses a wide range of anxieties and provides evidence-based CBT treatment [4] with accurate content and valuable features. preliminary usage data [3] is provided, including specifically for pediatric Obsessive Compulsive Disorder (OCD) [5] and have completed a pilot study to assess the feasibility and effectiveness of the app [6]. They will soon be recruiting for a randomized trial. Despite the current lack of evidence, Anxiety Coach is practical and encourages real-life exposures with “in the moment” app use that is likely beneficial.

Usability
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The user interface is simple, uses familiar gestures and is intuitive. The psychoeducation section is mostly drill-down menus with minimal page scrolling. The anxiety self-test is very easy to complete and the anxiety rating scale is smooth and effortless. The To Do List is clear. Navigation is aided by an info button in the bottom right corner that provides clear instructions. The app is not visually appealing and there is a lack of multimedia content.

Privacy & Security
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Users must accept the End-User License Agreement (EULA) but do not need to register or log in to use the app. Age and sex is the only personally identifiable information collected. Data on how the app is being used are collected, de-identified, aggregated and disclosed for product development, medical education and research and publications. Collected data are stored on third-party servers, but not shared with third parties. You cannot set a password to limit access to the app.

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This app is developed by credible clinical psychologists and anxiety experts Dr. Stephen Whiteside, Director of the Pediatric Anxiety Disorders Program, Mayo Clinic, and Dr. Jonathan Abramowitz, University of North Carolina, both institutions with strong reputations. It was last updated in March 2016. It functioned very well, without stalling, but it did crash a few times and re-opened to where I had left off.

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The app is only available in English in the Apple App Store for $6.99, which is well worth the cost in my opinion. The language is targeted towards adolescents and parents, with simple, concise, easily understood writing, at or slightly above a Grade 8 level. The text size is consistent throughout and comfortable to read.

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MindShift

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MindShift is an anxiety self-management app developed by the Anxiety Disorders Association of British Columbia (AnxietyBC) and BC Children’s Hospital, both trustworthy sources. It is specifically designed to address everyday anxiety faced by adolescents and young adults (AYA) including worry, test anxiety, social anxiety, performance anxiety, dealing with conflict, panic and perfectionism. MindShift empowers AYA to “face challenging situations and take charge of your life” through anxiety-coping skills — Chill Out Tools — including audio-guided relaxation exercises, visualizations and mindfulness strategies. Users can customize the app to their specific problem areas and preferred anxiety-reducing skills and preventative strategies. Other strengths of this app include privacy as no user data is collected or transmitted, ease of use, visual appeal and free access. The app could benefit from more multimedia content and interactivity. Specifically, there are multiple YouTube videos of adolescents using MindShift accessible from the AnxietyBC website, but not within the app. Compared to Anxiety Coach, MindShift scores slightly lower due to a lack of supporting evidence, but does a better job of appealing to AYA. I would highly recommend his app to any AYA with anxiety.

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The core features of this app are based on CBT principles and start with the user identifying specific circumstances — My Situations — of anxiety they would like help with, followed by psychoeducation and a self-assessment to identify key issues within this problem area. Then users can select thoughts — Thinking Right — that challenge their anxiety, select skills to lower stress levels — Chill Out Tools — and behaviours to prevent or reduce anxiety in the future — Active Steps. Users can “star” their favourite thoughts, tools and steps for quick access. The Anxiety 101 section is a text-heavy introduction to anxiety with links to the AYA section of the AnxietyBC website. The app suggests users set reminders in their calendar to practice these skills, but there are no reminders within the app. In the Help section there is a list of Emergency Helplines for users in Canada.

Effectiveness
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This app addresses a number of common anxieties faced by AYA and provides self-help skills based on CBT [4]. The content seems consistent with a CBT approach, is practical and could be beneficial. However, Mindshift does not explicitly reference guidelines or provide evidence for the effectiveness of this app.

Usability
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The user interface is clear and appealing. It uses cool tones and crisp graphics although text-heavy sections use a small thin font style that requires extra focus to read. Navigation is simple, using familiar gestures, although the back button in the lower left corner took some getting used to. The anxiety rating bar and symptom self-test is very easy to complete as are the anxiety self-assessments. Aside from a few pictures and audio-guided Chill Out Tools, there is a lack of multimedia content.

Privacy & Security
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There is no formal EULA or privacy policy. A disclaimer states MindShift is for educational purposes only and not a substitute for professional mental health care. In the About the App section it is stated that no personal information is collected and data is stored locally on the device. It is unclear why this is not in the disclaimer and if usage data is still transmitted, as is common with most apps. Users can set a password to limit access to the app.

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This app is developed by two reputable organizations, AnxietyBC, a non-profit devoted to increasing the public’s awareness and access to evidence-based resources on anxiety disorders and BC Children’s Hospital. It was last updated in August 2016. The app functioned smoothly without stalling or crashing.

Accessibility
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The app is available in English only, in the Apple App Store and Google Play Store at no cost. The language is targeted towards adolescents and is exactly written to target this level – Grade 7 and 8. The text size and formatting purposely varies in some sections, which works in some cases but in others the text is difficult to read.

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thinkFull

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thinkFull is a general stress management app launched by Telus and developed by content partners Canadian Mental Health Association (CMHA) BC Division, teenmentalhealth.org, heretohelp.bc.ca and mindyourmind.ca. While designed specifically for AYA, anyone can use this app to record, track and share his or her daily stressors and levels of stress. The greatest strength of this app is the extensive database of tips for relieving stress, solving problems and living well in general. Users can favourite, upvote or downvote tips with a swipe, enabling the app to learn and customize to each user. Users are incentivized to record their daily stress and complete tips to earn stars. thinkFull is very easy to use, visually pleasing and accessible. It is free. The app is very text-heavy and could greatly benefit from more multimedia content and interactivity. Compared to Anxiety Coach and MindShift, I would recommend thinkFull to any AYA looking to better understand and manage their stress, whether anxiety-related or not.

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A core feature of the app enables users to record their stress level between 1 and 7 and then visualize patterns of stress by week, month or year that can be easily shared via email. The other core feature is an extensive database of tips for relieving stress that users can favourite, upvote or downvote, enabling the app to learn their preferences. However, the tips are quite varied in complexity, cost and accessibility, with many lacking specific instruction and thus difficult to complete. The Tips section is entirely text-based and could really benefit from interactivity and multimedia. Under the Home menu, the Get Help section lists various Canadian hotlines and websites.

Effectiveness
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This app generally addresses stress faced by AYA and seems to be a very effective tool to track stress. While the self-help tips are directly sourced from reputable organizations, they are not evidence-based. Some of the tips are practical and could be beneficial, but some tips would be challenging to complete. thinkFull does not explicitly reference guidelines or provide evidence for the effectiveness of this app.

Usability
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The user interface is clean, simple and calming. App navigation is very intuitive despite the app not using standard icons or menus. Use is aided by on-screen tutorials that can be enabled or disabled. The stress slider bar is smooth and stress graphs and charts are visually appealing and instinctive. There is no multimedia content.

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The EULA states the app is for educational purposes only and not a substitute for medical care. While their target audience is AYA, it is explicitly stated “if you are under 13 years old, you may not use the App”. Your first name is the only personally identifiable information collected but stored on the device. Data on how the app is being used is collected and sent to CMHA BC Division for product development and evaluation. You can set a password or use Touch ID to limit access to the app.

Reliability
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This app was developed by Telus, a private company, and gifted to CMHA BC Division a non-profit. It was last updated in February 2017. The app functioned smoothly without stalling or crashing.

Accessibility
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The app is available at no cost in English in the Apple App Store. The language is targeted towards AYA and is exactly written to target this level, Grade 7 and 8. The white text is consistent in size and formatting throughout and is easy to read.

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Breathe, Think, Do with Sesame By Sesame Street

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Breathe, Think, Do is an app developed by Sesame Workshop, the non-profit educational organization behind Sesame Street that aims to use the educational power of media to help children everywhere reach their highest potential. This app is very engaging as children help a familiar blue monster, Mondo, sequentially work through everyday frustrations like struggling putting on shoes, saying goodbye to mommy, stacking blocks, waiting in line or being afraid of the dark. Strengths of this app include directly appealing to young children using familiar characters in animations and interactions. There is excellent re-iteration and deliberate practice opportunities of a single concept. Other strengths include a parent’s section with more tips to help kids develop resilience and privacy as no personal information is collected. The app is perhaps too narrow in only offering one strategy to help calm the child, and some of the animations and activities may be too long to hold a child’s attention. I would recommend this app to parents of young children having difficulty with one of the addressed examples.

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The core feature of this app leads children through one of five problems by first showing them an animation of the problem Mondo Monster is facing. Then children tap on Mondo’s belly to help him take three slow deep breaths until he is calm. Finally, children pop thought bubbles to help Mondo think of three different strategies from which to choose to help him solve his problem. The goal of teaching children breathing, thinking and doing when frustrated or anxious is reinforced throughout. Children should easily identify with each of the five problems. There is a parent’s section with tips to help kids develop resilience in nine other challenging situations. It includes pictures and videos with familiar characters like Elmo. Some of animations in the app and activities — like popping thought bubbles – may be slow for toddlers. Interactivity and multimedia are used very well in this app.

Effectiveness
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If this app holds your young child’s attention for long enough, it could be a very effective tool to teach them to Breathe, Think and Do when faced with problems. Although Sesame Street is a reputable children’s company, this app is not evidence-based. The Breathe, Think, Do strategy and other tips are practical and could be beneficial but may not work in all situations. There are no guideline references or evidence for the effectiveness of this app.

Usability
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The user interface and navigation is intuitive and aided by verbal instructions to walk children through each step of the app. Some of the tapping is inaccurate and not as responsive as I would expect including tapping on Mondo’s belly, popping thought bubbles, selecting the Home or Parent only section, and dragging parent tips to a corner.

Privacy & Security
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The app links to a Sesame Workshop privacy policy for all platforms. Anonymous information is automatically collect to support internal operations, understand and monitor usage and improve performance. When personal information is expressly requested, they explain how it will be used. They follow the Children’s Online Privacy Protection Act (COPPA), a law designed to protect the online privacy of children under age 13. You cannot set a password to limit access to the app.

Reliability
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This app is by Sesame Workshop, a Sesame Street non-profit educational organization. It was last updated in June 2016. The app stalled on certain screens, as the Home or Back icons disappear until the activity is complete or users are not able to tap back. The app does not contain any inappropriate material, games or advertising.

Accessibility
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The app is available at no cost in English and Spanish in both the Apple App Store and Google Play store. It is a hefty 471 MB, which could be a barrier to storage. The app targets children aged 2 to 5 and their parents and does this exceptionally.

References:

1. Katzman, Martin A., et al. “Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders.” BMC psychiatry 14.1 (2014): S1.
2. Bernstein, Gail A. and Kailie Shaw. “Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders.” Journal of the American Academy of Child & Adolescent Psychiatry 36.10 (1997): 69S-84S.
3. Whiteside, Stephen PH. “Mobile device-based applications for childhood anxiety disorders.” Journal of child and adolescent psychopharmacology 26.3 (2016): 246-251.
4. James, A. A. C. J., Angela Soler and R. Weatherall. “Cognitive behavioural therapy for anxiety disorders in children and adolescents.” Cochrane database of systematic reviews 4 (2005).
5. Whiteside, Stephen PH, et al. “Case examples of enhancing pediatric OCD treatment with a smartphone application.” Clinical Case Studies 13.1 (2014): 80-94.
6. ClinicalTrials.gov. Bethesda (MD): National Library of Medicine (US). 2014 Jul 29. Identifier NCT02205177, Youth Mayo Clinic Anxiety Coach Pilot Study; 2017 Apr 4 [cited 2017 Aug 19];. Available from: http://clinicaltrials.gov/ct/show/NCT02205177

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