Author
AHMEAD Muna; BOWER Peter;
The effectiveness of self help technologies for emotional problems in adolescents: a systematic review.
Journal citation/publication details
Child and Adolescent Psychiatry and Mental Health, 2(20), July 2008, 12pp.
Summary
This review of 14 mainly US studies finds small or medium sized effects for self-help technologies on attitudes to self, social cognition and emotional symptoms among adolescents, defined as aged 12-25. However, none reached statistical significance. The small number and poor quality of the studies mean that self-help modes of delivering interventions for emotionally disordered adolescents cannot be recommended until more rigorous studies have been conducted.
Context
Emotional disorders such as depression, anxiety and obsessions are relatively common among adolescents and although they may not necessarily reach clinical thresholds, they can affect functioning and lead to more severe disorders if untreated. Psychological therapies can be effective but access is limited, and self-help approaches have been shown to be effective with adults. This review examines the evidence for their effectiveness with younger people.
Methods
What sources were used?
The following databases were searched by the lead author in late 2004/early 2005, with updating searches conducted in April 2006: CINAHL (Cumulative Index to Nursing and Allied Health Literature), from 1982; the Cochrane Controlled Trials Register; EMBASE (Excerpta Medica), from 1980; Medline, from 1966; and PsycINFO, from 1967. Google Scholar was also ‘searched regularly’ between 2004 and 2006. Figure 1 lists nine journals that were identified from scoping searches as particularly relevant and hand searched from the first issue of 1995 to March/May 2005. The reference lists of all identified studies were also checked.
What search terms/strategies were used?
The Medline search strategy is given in full and included four sets of terms covering adolescents, technology, self-help and mental health treatment. However, the authors make clear that specific search strategies were developed for each database to maximise the chances of retrieving relevant studies. In particular, study design terms were not included because ‘some quasi-experimental studies may not be correctly indexed’, and terms related to specific problems or disorders were also excluded.
What criteria were used to decide on which studies to include?
Eligible studies were RCTs and quasi-experimental studies with control groups, conducted with populations aged 12-25 exhibiting emotional symptoms and exposed to self-help interventions delivered through the internet or stand-alone computer programs, or through paper-based materials, audiotape or videotape. The outcomes of interest were attitude towards self (e.g. self-concept and self-esteem) and social cognition (e.g. self efficacy, locus of control). Only English language studies were eligible because of the lack of a budget for translation.
Who decided on their relevance and quality?
The searches, which were deliberately broad in design, delivered 55,480 studies. Titles and abstracts were checked by the first author, with both authors discussing those that appeared potentially relevant and reaching decisions on inclusion. Subsequent filtering of the studies to arrive a set for review is summarised in a flow chart at Figure 2. The authors independently assessed the selected studies for methodological quality using the Quality Rating Scale.
How many studies were included and where were they from?
Fourteen studies were reviewed, 13 from the USA and one from Australia, and are summarised in Table 1.
How were the study findings combined?
Data on methods, populations, interventions and outcomes were extracted independently by two individuals (probably the authors although this is not clear), with disagreements resolved by discussion or recourse to the authors of studies. The meta analysis used the standardised mean difference estimate of effect size.
Findings of the review
Twelve of the studies used students (school or college) recruited as volunteers, and only two reported the inclusion of clinical participants. Most included a mix of males and females (but with more of the latter) but only two reported on the number of eligible participants who did not participate to judge the representativeness of those that did. Overall, the methodological quality of the six RCTs and eight quasi-experimental studies was low, with a mean quality score of 14.2 out of a possible 42.
Four of the studies used computer-based interventions (despite the ‘explosion in the use of the internet’), eight used bibliotherapy and two used videotapes. In seven studies participants used the materials alone at home but in the remainder they worked in group sessions lasting between 30 and 60 minutes, with minimal instruction from therapists or researchers.
Despite the prevalence of depression among adolescents, only two studies addressed this although six examined other outcomes theoretically or empirically related to depression. The remaining six looked at anxiety.
The studies delivered very varied results and, as a result, meta-analysis was conducted using a random effects model. This found a small effect size for the effect of self-help technology on attitudes towards self (-0.14; five studies); a medium effect size for the effect on social cognition (-0.49; three studies); and a medium effect size for the effect on emotional symptoms (-0.47; seven studies). None of these effect sizes was statistically significant although the last did approach this threshold.
Authors' conclusions
The limited number of studies identified, despite an extensive search, and their generally poor quality mean that ‘the results of the review can only be considered preliminary until the completion of more rigorous studies’.
The results for emotional symptoms are similar to those found in reviews of the use of self-help technology with adults but, in general, the effect size estimates are lower than those found in studies of older people. This may reflect differences between adolescents and adults, but could also result from methodological differences between studies or their variable quality.
The authors also note the limited generalisability of the findings. Virtually all the studies were conducted in the USA, few reported the number of eligible participants who took part, only two included clinical participants, and most used inclusive age ranges rather than distinguishing between younger and older adolescents.
Implications for policy or practice
‘The implementation of self-help technology for adolescents with emotional problems would be premature until further high quality randomized controlled studies are conducted.’ These need to compare self-help technology with usual care, and various types of self-help technology with each other. Suitable follow-up periods are needed (i.e. more than the six months or less characteristic of the reviewed studies), and potential moderators of treatment effects such as age and gender need to be considered.