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The aim of this study is to test the effectiveness of a single-session, digital intervention teaching the principle of practicing the opposite, when administered to youths on the waitlist for psychotherapy, with usual waitlist procedures as a control condition.
There is a massive unmet need for youth mental health care in America; only ¼ of youth in need receive services. The problem has been underscored and exacerbated by the pandemic. The need for child and adolescent mental health care, particularly for depression and anxiety, has surged while clinician availability and clinic funding have shrunk. One result is that clinic waitlists, always lengthy, have stretched, with youths and families who seek care waiting for up to 12 months for a first appointment, and many giving up and dropping out before the much-delayed appointment. There is a clear need-in both pandemic and normal times-for efficient mental health support that can be provided when need is acute, to sustain young people through periods of delayed access, and to reduce burden for professionals. Fortunately, recent evidence shows the surprising potential of brief, low-cost, digital interventions that could go a long way toward bridging the need-to-access gap. Single-session interventions have substantial effects, in some cases rivaling effects of full-length in-person psychotherapy. Remote therapies for youth mental health problems are beneficial on average and approximately as beneficial as in-person psychotherapy.
The current trial will test a brief (one 30-45-minute session), online, interactive mental health and behavior change intervention for adolescents (9-17 years old), who have been placed the waitlist for outpatient treatment at participating mental health clinics in the United States. Previous RCTs show beneficial effects of the principle of Practicing the Opposite (PTO) on youth mental health when using the therapeutic elements present in PTO (e.g., exposure, to overcome anxiety; behavioral activation, to overcome depression). The single-session PTO intervention uses stories, interactive activities, and engaging graphics to teach youths a key principle: by practicing the positive opposite of unhelpful behaviors, one can, over time, change their emotions thoughts, and actions.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Practicing the Opposite (PTO) intervention | Experimental | This 30-45 minutes Qualtrics-based, digital program uses stories, interactive activities, and engaging graphics to teach youths one core principle: by practicing the positive opposite of unhelpful behaviors (e.g., engaging with rather than avoiding feared stimuli), one can, over time, change their mood, thoughts, and actions. The intervention is comprised of four main sections: 1) An introduction to PTO; (2) Testimonials from young people who have been helped by PTO; (3) Learning how to Practice the Opposite through online activities. (4) Planning how to continue to Practice the Opposite in the participant's life. Of note, after being removed from the waitlist at the clinic and contacted to begin treatment, participants will still receive treatment as usual from the clinic. |
|
| Usual waitlist control group | Other | Usual waitlist procedures involve watchful waiting for a therapist to become available, sometimes complemented by periodic check-ins from the family with clinic administrators. After being removed from the waitlist and contacted to begin treatment, participants in both study conditions will receive treatment as usual in the clinic. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Practicing the Opposite (PTO) | Behavioral | This 30-45-minute digital program is designed to help youths on the waitlist feel better prior to treatment and may also improve their treatment engagement and outcomes. |
| Measure | Description | Time Frame |
|---|---|---|
| Behavior and Feelings Survey (Youth and Parent Versions) | Assesses the child's thoughts and feelings over the past week using both youth and parent report. Both the youth and parent report surveys include 12 items each scored from 04, with higher scores indicating more severe symptoms. Consists of an internalizing and externalizing subscale, the trajectories of which will be analyzed separately and compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and monthly follow-up until completion of clinic treatment or 1 year, whichever comes first. |
| Generalized Anxiety Disorder 7-item scale (GAD-7) | Assesses via a 7-item youth self-report questionnaire (in which scores range from 0-21, and higher scores indicate more severe symptoms) the youth's experience of anxiety symptoms. Trajectory of change on this measure will be compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and monthly follow-up until completion of clinic treatment or 1 year, whichever comes first. |
| Patient Health Questionnaire 8-item scale (PHQ-8) | Assesses via an 8-item youth self-report questionnaire (in which scores range from 0-24, and higher scores indicate more severe symptoms) the youth's experience of anxiety symptoms. Trajectory of change on this measure will be compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and monthly follow-up until completion of clinic treatment or 1 year, whichever comes first. |
| Measure | Description | Time Frame |
|---|---|---|
| Ecological Momentary Assessment (EMA) Survey | Consisting of a modified Positive and Negative Affect Scale (PANAS) and a modified Coping Questionnaire, this 8-item measure is administered 3 times daily via an EMA mobile application called Metricwire. It assesses affect and behaviors via youth self-report. | Scores on each item will be compared across 1 week before the PTO intervention and 2-weeks after. The association between change in behaviors and change in affect across these time ranges will be assessed. |
| Measure | Description | Time Frame |
|---|---|---|
| Feedback Questionnaire | Elicits feedback from the youth about the digital practicing the opposite program. | immediately post-intervention |
| Demographic Questionnaire | Asks caregiver and youth for basic youth and family demographic information. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Katherine Venturo-Conerly, A.B. | Harvard University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Riley Child Psychiatry and Behavioral Sciences Clinic | Indianapolis | Indiana | 46202 | United States | ||
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| ID | Term |
|---|---|
| D001008 | Anxiety Disorders |
| D003863 | Depression |
| D019955 | Conduct Disorder |
| ID | Term |
|---|---|
| D001523 | Mental Disorders |
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
| D019958 | Attention Deficit and Disruptive Behavior Disorders |
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Participants, 9-17 years old, will be: randomized to a 30-45-minute Qualtrics-based, digital program teaching Practicing the Opposite (PTO, followed by psychotherapy) or to the usual care (i.e., usual waitlist procedures, followed by psychotherapy) control.
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| Usual Clinical Care | Other | Usual care provided by participating youth mental health clinics in the United States. |
|
| Revised Children's Anxiety and Depression Scale (RCADS) Parent Version (Short Form) |
Trajectory of change on this 24-item parent-report measure of anxiety and depression (in which scores range from 0-72 and higher scores indicate more severe symptoms) will be compared between the intervention and control group. Trajectories of change on the subscales within this measure (broad anxiety and depression) may also be analyzed similarly. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. |
| Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and monthly follow-up until completion of clinic treatment or 1 year, whichever comes first. |
| State Hope Scale | Assesses the child's current level of hope using a six-item self-report scale, in which each item is scored from 1 to 8, with higher scores indicating greater hope. Trajectory of change on this measure will be compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and 1-month follow-up. |
| Perceived Control Scale for Children | Assesses via a 24-item self-report scale the youth's beliefs about their ability to control and change their environment. Total scores range from 0-72, with higher scores indicating greater perceived control. Trajectory of change on this measure will be compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and 1-month follow-up. |
| Secondary Control Scale for Children | Assesses via a 20-item self-report scale the youth's beliefs about their ability to control and change their emotions and thoughts. Total scores range from 0-60, with higher scores indicating greater secondary control. Trajectory of change on this measure will be compared between the intervention and control group. Note that timing described below may be adjusted if response or feedback suggests excessive measurement burden. | Trajectory of change in scores compared across intervention and control groups from baseline, through post-intervention, 2-week, and 1-month follow-up. |
| Clinic Record Data | For those participants who authorize investigator access to their clinic record data, the investigators will also compare rates of accessing and completing clinic treatment, as well as attendance at sessions, between the intervention and control groups. | Through study completion, an anticipated average of 6-months |
| pre-intervention |
| Boston Child Study Center |
| Boston |
| Massachusetts |
| 02116 |
| United States |
| The Baker Center for Children and Families | Boston | Massachusetts | 02120 | United States |
| The Concord Center | Concord | Massachusetts | 01742 | United States |
| Riverside Community Care | Dedham | Massachusetts | 02026 | United States |
| D065886 | Neurodevelopmental Disorders |