YOUTH MENTAL HEALTH CURRENT USE DEVELOPMENT AND OPPORTUNITIES FOR INTERVENTION AND DESIGN

The growing reliance of youth on online support for mental health represents an opportunity for providers of mental health services, apps, and other supports. Online spaces offer unique affordances that can help create scalable, personalized, and timely interventions. For example, we may be able to reach youth who are difficult to reach through more traditional clinical supports or in moments when current providers do not have visibility. Many people, especially youth, may not want traditional mental health support. An online screening platform hosted by Mental Health America, which has screened millions of people for mental health issues, found that only 17 percent want a referral to traditional help, but 44 percent want some form of online or mobile platform that can help them manage their own symptoms. This is not surprising. Online spaces offer opportunities for enhanced disclosure and anonymity while increasing convenience and ability to access help in times of need. Youth may also uniquely benefit from peer social and emotional support in these kinds of online settings. Furthermore, youth are more likely to want to seek resources. Compared to the national average, millennials are more likely to find treatment and more likely to take an additional step after receiving a screening result. Despite being more willing to seek care, youth often face barriers to traditional care pathways, including their parents, and might be even more likely to seek innovative resources. Thus, online spaces are opportune for this population.

Other considerations include ecologies of care during adolescence which include family and parents, schools and traditional mental health services and providers. Youth patterns of interacting with technologies will be indicative of how they may want to use tools online surrounding mental health domains. Studies have shown that cognitive behavioural therapy (CBT) apps are viewed as more relevant than game-based apps and various engagement strategies are appealing to youth. A one-size-fits-all approach is unlikely to work and considerations around multiple app and platform usage along with affordances will help tailor a toolkit for this population, developmental stage, and target needs.

Current Use and Development

of Technologies for Mental Health

Recent years have seen tremendous growth in efforts to leverage digital and networked technologies to support mental health. These tools and approaches can be broken into categories based on their targets, including promotion of (1) general wellness (e.g., social and emotional learning, happiness, wellbeing), (2) mental health (e.g., depression, anxiety, stress), and (3) brain fitness (e.g., cognitive processes such as working memory). Several tools have been tested and developed in children and adolescents and there is clear evidence for the benefits of such tools—enough evidence such that the National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom endorse digital cognitive behavioural therapy (CBT) as the preferred frontline treatment for depression for children and adolescents. Most effective tools lean on evidence-based principles from established therapies, for example, CBT, mindfulness, cognitive training, and biofeedback. Many other types of tools in this space exist and may have some evidence of effectiveness resulting from small deployments or feasibility trials. However, questions abound, including whether youth will continue to use these tools in real-world settings and the sustainability of benefits.

One of the most significant current challenges is that despite the robust evidence that such technologies can be beneficial, relatively few adolescents are using mental health apps. In a recent study of 775 girls (ages 11–16), 6 percent reported using a mental health app, despite 48.5 percent indicating they would use a mental health app for support. Millions of youth, however, are still left untreated or under-treated. Many apps that are developed and evaluated never make their way to the commercial marketplace to be available to consumers. Of those that do, few are well integrated into systems of care or digital ecologies, requiring youth to come find them rather than being findable by youth where they are. We conducted an analysis of available apps for youth mental health in order to better understand where developers were focusing their efforts, and what was available for youth.

The researchers have focused on summarizing the research evidence of the effectiveness of apps focused on youth mental health. This overlooks apps that may be available for youth to download and use but that have not been directly evaluated in a research study, which estimates have suggested are likely 95–99 percent of the available apps. The reviews that do survey available apps more broadly usually focus on quantifying the “best” or “top” apps in a category. Our team took a different approach in order to understand the depth and breadth of available apps for youth mental health. Our goal was to characterize variation in approaches in order to understand the potential affordances of technology in this space.

In a systematic search in recent past year of published reviews, web and mobile searches including Apple iTunes and GooglePlay stores, social media, and top app lists, when looking for apps intended for children and young adults that were currently available and found that we thought deserved consideration. It was analyzed them in relation to features interested in: (1) apps with direct research evidence, (2) apps that were the most downloaded, (3) apps with social features, (4) apps with game features, (5) apps that included features for child and parent collaboration, (6) apps that were tailored or designed for minoritized or underserved populations, and (7) any app with additional “interesting” features or components. Notably, only one app fit the “social” category and no apps fit under the “minoritized or underserved population” category. Mindfulness was a popular type of intervention and gamification was a popular approach to promote engagement. In many ways this mirrors the adult intervention space, despite multiple findings from research studies that youth want strategies and styles that match the way they like to use technology. Many apps do surface level tailoring to make the app seem relevant to youth. This might include changing the images and aesthetics but retaining the language for adult-focused interventions. 

Other considerations include ecologies of care during adolescence, which include family and parents, and traditional mental health services and providers. Youth patterns of interacting with technologies will be indicative of how they may want to use tools online surrounding mental health domains. Studies have shown that cognitive behavioural therapy (CBT) apps are viewed as more relevant than game-based apps and various engagement strategies are appealing to youth. A one-size-fits-all approach is unlikely to work and considerations around multiple app and platform usage along with affordances will help tailor a toolkit for this population, developmental stage, and target needs.

Recent years have seen tremendous growth in efforts to leverage digital and networked technologies to support mental health. These tools and approaches can be broken into categories based on their targets, including promotion of (1) general wellness (e.g., social and emotional learning, happiness, wellbeing), (2) mental health (e.g., depression, anxiety, stress), and (3) brain fitness (e.g., cognitive processes such as working memory). Several tools have been tested and developed in children and adolescents and there is clear evidence for the benefits of such tools—enough evidence such that the National Institute For Health And Care Excellence (NICE) guidelines in the United Kingdom endorse digital cognitive behavioural therapy (CBT) as the preferred frontline treatment for depression for children and adolescents. Most effective tools lean on evidence-based principles from established therapies, for example, CBT, mindfulness, cognitive training, and biofeedback. Many other types of tools in this space exist and may have some evidence of effectiveness resulting from small deployments or feasibility trials. However, questions abound, including whether youth will continue to use these tools in real-world settings and the sustainability of benefits.

One of the most significant current challenges is that despite the robust evidence that such technologies can be beneficial, relatively few adolescents are using mental health apps. In a recent study of 775 girls (ages 11–16), 6 percent reported using a mental health app, despite 48.5 percent indicating they would use a mental health app for support. Millions of youth, however, are still left untreated or under-treated. Many apps that are developed and evaluated never make their way to the commercial marketplace to be available to consumers. Of those that do, few are well integrated into systems of care or digital ecologies, requiring youth to come find them rather than being findable by youth where they are. We conducted an analysis of available apps for youth mental health in order to better understand where developers were focusing their efforts, and what was available for youth.

Our review of opportunities for intervention and design uncovered a significant gap between youth desire for mental health support and what is being offered by digital mental health professionals. Youth are more open about mental health issues and mental health treatment than previous generations. This desire to seek mental health support, however, is not necessarily a desire for traditional mental health services. Instead, youth are more open- minded about where this support might come from, and they are actively supporting one another’s wellbeing through social media. There appears to be a mismatch between current digital mental health supports and where youth are digitally, developmentally, cognitively, and emotionally. Digital mental health supports need to be developed to match the online spaces youth populate and to fit their interests, needs, and capabilities.

Youth mental health has problems and gaps I.e.:

• Digital mental health developers and providers need to be responsive to youth needs and interests if they want their products to be adopted by youth. These efforts could be better informed by development science and a developmental approach, as well as by research on youth online engagement.

• Researchers need to study what is being adopted and why, as well as the effectiveness and limitations of interventions, if we want programs to be both effective and widely adopted.

Our review identified opportunity areas with high youth interest and engagement that are under leveraged by the digital mental health field. These include:

• Integrating cognitive and behavioural skills, which are of high interest among youth, within digital ecologies,

• Meeting youth where they are in digital communities, such as online forums addressing social and emotional concerns, or through quick, “bite-sized” interactions that fit adolescent use in online spaces such as social media, messaging, and video platforms (e.g., YouTube),

• Addressing stressors in friendships and romantic relationships that span both in- person and online engagement rather than treat phenomena such as cyberbullying and sexting that occur primarily online,

• Supporting and training organizers and influencers in youth online networks, including developing targeted mental health products, toolkits, and training on the use of digital mental health tools, or content and training for online moderators and influencers,

• Targeting and tailoring efforts to vulnerable subgroups of youth, particularly those who experience vulnerability because of social marginalization and who have potentially the most to gain from digital connections with supportive peers and professionals,

• Recognizing that existing social networks, including peers, parents, and educators, are potential avenues for spreading and scaling of these tools, given that communication is highly digitally networked,

• Tapping diverse youth as agents, experts, innovators, and communicators who are often best equipped to support one another’s wellbeing in online spaces and who could contribute to collaborative efforts with mental health professionals and technology developers.

A range of relevant research and development efforts for youth mental health is to identify gaps and opportunities in how to support adolescent wellbeing in a digitally networked world. Given the rising rates of mental health concerns among young people in the countries, we see urgency in focusing research, investment, and public attention on what actually drives and mitigates mental health problems for youth. In particular, we worry that a common but unsubstantiated assumption that social media are a negative influence has deflected attention from the real stressors that young people experience, including social marginalization, instability, and conflict both online and offline. We also note that despite the rapid growth of digital mental health apps, these products are largely untapped by youth and they do not address their unique needs and interests.

As we consider ways of supporting mental wellbeing, we see opportunities for mental health professionals to reach young people where they are, in social media platforms and online affinity groups. We also highlight the ways in which young people see social media as a lifeline to social support, and how they are actively supporting each other online in times of need and crisis. Perhaps most important, we underscore the diversity of youth needs, interests, and vulnerabilities, and the importance of recognizing that one-size-fits- all solutions are ineffective and do not target those with highest need. Indeed, evidence is robust that the most vulnerable teens have the most to gain from social support from caring peers and adults both offline and online. We urge developers, parents, clinicians, and other stakeholders to recognize the unique and diverse needs and assets of youth, to look to social media as a potential amplifier of both risks and benefits, and to actively involve youth in the development of a healthy online ecosystem.

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