Evidence
Alert

Digital games, apps and e-therapy show promise for helping children manage obesity, anxiety and other long-term conditions

Digital interventions such as games, apps and e-therapy may encourage primary school-aged children to exercise more or manage their anxiety, but research into the benefits of the technology for this age group is thin on the ground.

Long-term conditions are becoming more common. Some can be improved by changes to behaviour, such as a better diet for obesity, rigorously following a care plan for asthma or specific activities to improve balance in cerebral palsy. Digital technology can help adults and teenagers change their behaviour, but there is little evidence about its effectiveness in children under 12.

A review of the evidence included 17 studies in which children under 12 used digital technology to help them adopt habits that can improve long-term conditions. The researchers found five studies with ‘quite promising’ results. The most promising interventions included support from a healthcare professional, involved parents, and used games (such as exercise games).

Digital technology could be used by medical staff treating children with long-term conditions but should include monitoring and long-term follow up to better understand its effects. New programmes in development should consider including healthcare professional support, involving parents and using digital games.

What’s the issue?

Increasingly, digital technologies are helping people manage their long-term conditions. Interventions are delivered via television, laptops, smartphones and wearable devices. They include computer-based cognitive behavioural therapy (CBT) to treat anxiety and depression, as well as apps or programmes to encourage people to exercise more, eat more healthily or give up smoking.

Digital technologies may be easier for people to access, and they may appeal to some more than face-to-face sessions with a healthcare provider. Reduced involvement by healthcare providers also saves resources.

However, there is little research on their suitability for children aged 12 or younger. This study aimed to summarise existing research, to find out whether these technologies are useful for children, what features make for a successful programme, and how children and their parents experience them.

What’s new?

The researchers carried out a systematic review. They included 17 randomised trials of digital technologies used with children aged 5 to 12. The children had a range of conditions including obesity anxiety, diabetes, asthma and cerebral palsy.

They found:

  • Some programmes for children who were overweight or obese were ‘quite promising’. Two were Xbox games, played wearing a Fitbit. These increased the time children spent exercising, though did not reduce their weight. One programme used training sessions (in person and online) and showed weight loss.
  • Programmes for children with anxiety-related problems were also ‘quite promising’. Two delivered cognitive behavioural therapy (CBT) online and both reduced children’s anxiety scores.
  • Some technologies were classed as ‘possibly promising,’ but the researchers said their scientific basis was weak. An app for children to use before surgery encouraged relaxation and reduced anxiety. A computer game led to some improvements in balance for children with cerebral palsy. A game for children with attention deficit hyperactivity disorder (ADHD) improved children’s time management but not their planning or social skills.
  • Several interventions showed no promise. One-way motivational texts did not help overweight or obese children; nor did an exercise game coupled with sessions in the classroom. A video game did not stop children bullying others.
  • Other studies looked only at whether an intervention was possible, not at the outcomes in children.

A common feature of the most promising interventions (quite promising and possibly promising) was that they included some support from a health professional, either an initial appointment or ongoing support.

These interventions involved the child, often through games that delivered feedback and monitoring, knowledge, repetition, and reward. These are key techniques for changing behaviour and successful interventions used more than one of these techniques. Features for parents typically included setting goals, planning and social support.

There was little research asking children or parents about their experience with the programmes. Where it had been carried out, parents said they had learned more about their child’s condition, which had changed their behaviour and helped their child in turn. Parents valued professionals’ input and felt their children were more likely to listen to them. Some questioned whether the programme was suitable for the children’s stage of development and said they would like apps to be personalised to reflect children’s preferences. Content needed to change to keep engaging children over time, they said.

Why is this important?

Children may live with long-term conditions for decades. Helping them to change their behaviours and manage their condition better could have a life-long impact. Digital interventions may allow this to be done at scale, and in a cost-effective way, so more children can benefit. However, it is vital to know which interventions work before rolling them out.

This review suggests exercise games for children with overweight and obesity, and online CBT for children with anxiety conditions, can work. The limited research uncovered by this review means that, although they could be introduced as pilot programmes in clinics, they should continue to be reviewed and evaluated to see how they work in the real world. Other interventions need to be developed for other conditions.

The review also points to important factors to consider when designing programmes for children in this age group, such as child-friendly design, and clinician and parent involvement.

What’s next?

The lead academic for this study is interested in how digital interventions can help children at school, as well as at home. As the review found no promising interventions for the classroom setting, she plans to conduct research with teachers and others to investigate what they would find helpful. The aim is to design digital programmes that can be used by the child, parent, clinician and teacher, to help the child manage their condition.

It is not clear how widely digital technologies are being used in primary school-aged children with long-term conditions, and further research is needed. NICE guidance on childhood obesity from 2013 states that children should have access to a tailored lifestyle weight management programme, but it does not include specific guidance on using digital tools. NICE recommendations published in 2020 covered the development of digital technologies for behaviour change, but are not specifically aimed at children.

You may be interested to read

The full paper: Brigden A, and others. Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review. J Med Internet Res. 2020; 22:e16924

A paper providing an introduction to the area of digital intervention development: Yardley L, and others. The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions. J Med Internet Res. 2015;17:e30

NICE Public Health guidance: Weight management: lifestyle services for overweight or obese children and young people [PH47] 2013

NICE guidance: Behaviour change: digital and mobile health interventions [NG183] 2020

 

Funding: This research was funded by the NIHR Doctoral Research Fellowship programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

The review identified some potentially promising interventions that, with a bit of further testing and monitoring, could be useful to start using with this age group. They were effective in research and could now be trialled in clinical settings. It could be a good time to work towards integrating them into clinical practice, with further monitoring and research about how they work in practice.

Quite a few papers were early feasibility studies, with not enough data behind them. There is some really good research going on but for some reason it is not going through to full scale evaluation and implementation. Research gets so far then falls off a cliff.

Amberly Brigden, Research Associate, Centre for Academic Child Health, University of Bristol

Young person

I’ve got asthma and I have to take a pill in the morning with a puff of my inhaler and a different pill at night. You take one after food, and one before food. And I have to write down how hard I can blow every morning and evening. It’s quite hard to remember it all and I’m always forgetting something.

I’ve got a phone and I play games and watch videos. In one game you look after a cat and his friends, you make sure he gets food, sleep and clothes. You play games and do different things to unlock higher levels and I never get fed up with it. It would be good if one of the animals made it look fun to take pills and told you when it’s time to take yours. Then I would do it.

Some other games have chats. If I could talk to someone else who has asthma, that would be nice.

Chloe Brosnan, Age 10, Public Contributor, Abingdon

Researcher

There is a strong argument for digital behaviour change interventions to support the management of long-term conditions. But as the review highlights, their effectiveness in childhood conditions has not been widely explored.

This review is the first to identify effective digital interventions for younger children (5-12 years), report the characteristics of interventions and describe users’ experience. These findings will have an impact on a wide audience, including researchers, clinicians, and policy makers. Parents may also be interested to learn more about how face-to-face interventions that include digital tools (such as interactive websites) might help children with long-term conditions.

It might be helpful for future research to consider how available apps could be tailored (with clinical and behaviour science support) to help with the management of long-term conditions in children. In future, as the review highlighted, it is important to evaluate any form of digital intervention from the users’ point of view, including the young children themselves, parents and clinicians. The review findings provide an evidence base for future research.

Mandeep Sekhon, Research Associate, School of Population Health and Environmental Sciences, Kings College London