Digital health interventions (DHIs), including computer-assisted therapies, smartphone applications and wearable technologies, are anticipated to transform the way mental health interventions are delivered and received, potentially improving their clinical efficacy. This review investigated whether DHIs live up to their expected impact on the management of mental health conditions by reviewing the evidence for their clinical and cost-effectiveness, and by identifying key research questions and methodological and clinical issues related to their development, assessment and application.
This report collates information from sources identified through a meta-review search for scoping, narrative and systematic reviews examining the efficacy of DHIs in improving mental health outcomes in children, adolescents and young adults. The reviews were identified based on a keyword search* conducted using multiple databases† with a cut-off publication date of 1 November 2015. In addition, a systematic review search for randomised controlled trials (RCTs) of DHIs in subjects aged <25 years published between June 2013 and the end of December 2015 was performed.
None of the 20 reviews included discussed the effectiveness of DHIs in ADHD, and 10 RCTs examined computer-based cognitive training interventions‡ for the management of ADHD symptoms and behaviours in patients with ADHD.
The findings regarding the benefits of neurofeedback training (NFT) were conflicting. In two studies, NFT did not demonstrate superiority to placebo in improving parent-, and/or investigator-, and/or teacher-rated ADHD symptoms. When used as a treatment augmentation with methylphenidate, NFT yielded significant improvements in social functioning and parent-rated ADHD symptoms relative to methylphenidate plus placebo. As compared with children with ADHD receiving cognitive training interventions, those who received NFT experienced an improvement in parent-reported executive function, behaviour regulation and meta-cognition outcomes, as well as teacher-reported attention and inattention outcomes.
Across three different RCTs, the effects of working memory training (WMT) on ADHD symptoms were inconsistent. In one study, the WMT group demonstrated higher improvements in verbal and non-verbal memory relative to placebo. In another study, WMT demonstrated improvement in mathematics and reading skills relative to the control group, but no differences were observed on parent- and teacher-rated ADHD symptoms. In a third study, the degree of improvement on one verbal memory task was higher in the WMT group than the placebo group, but the improvement in other ADHD symptoms was not statistically different between the two groups.
A study examining interventions targeting multiple aspects of executive functioning indicated that there was evidence of improvement in ADHD symptoms regardless of the intervention used. Treatment delivered via videoconferencing resulted in greater improvements in ADHD symptoms per teacher or caregiver rating relative to the control group.
Multiple methodological factors should be considered when drawing conclusions from trials investigating the effects of DHIs on ADHD symptoms. These include variability in uptake and adherence to DHIs and the absence of a unified system for their classification, in addition to the small study sample sizes, the lack of blinded outcome evaluation, combining different comparators, short durations of follow-ups and inadequate specification of the extent of human support in the studies. In view of the inconsistency of the results of RCTs, there remains a lack of solid support for the benefits of these types of interventions, and as such their use in the treatment of ADHD is not encouraged.
*Medical Subject Heading (MeSH) terms reflecting study population (e.g. children; adolescents; young people), mental health disorders, DHIs (e.g. Internet interventions, apps, eHealth) and subtypes of review included in the meta-review
†Allied and Complementary Medicine, Ovid, MEDLINE, PsychINFO, PsychARTICLES, Embase, PubMed, ASSIA, Cochrane Library, CINAHL and Web of Science, and JMIR Publication database
‡Electroencephalogram-based neurofeedback training (NFT) (n=2); NFT augmenting treatment as usual (n=2); NFT with medication (n=1); working memory training (WMT) (n=3); executive functioning training (EFT) (n=1); treatment delivered via videoconferencing (n=1)
Hollis C, Falconer CJ, Martin JL, et al. Annual Research Review: Digital health interventions for children and young people with mental health problems: a systematic and meta-review. J Child Psychol Psychiatry 2016; Epub ahead of print.