An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study.

BACKGROUND: Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure. OBJECTIVE: We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals. METHODS: We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus. RESULTS: Parents rated their child's difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo's strong ease of use and high acceptability. In the exit survey, parents rated their child's fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=-4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child's fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game's interactive design, as observed in 69% (24/35) of our participants. CONCLUSIONS: The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children's fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern.

National Norms and Percentiles for the Pediatric Emotional Distress Scale.

We estimated norms and percentiles for the Pediatric Emotional Distress Scale (PEDS) in order to enhance its utility as a screening tool for emotional and behavioral distress following a major. The PEDS was administered to a nationally representative sample of parents of children ages 5-12 from all 50 states (N = 1,570). Approximately 15% of the parents reported a trauma/stress in the past 12 months. Results showed good internal consistency (α = .92) and concurrent validity, with significantly higher scores for the trauma/stress subsample compared to the no trauma/stress subsample. PEDS scores were also significantly higher in younger children (age 5-6) compared to older children (7-12), pointing to the need for separate clinical cut-off scores for younger versus older children. Finally, we examined the factor structure of the PEDS with results supporting a four factor solution in the trauma/stress subsample. For screening purposes, we recommend cut-off scores of 39 (ages 5-6) and 35 (ages 7-12) which correspond to the 90th percentile.

Quantifying Potential Bias Resulting From Child Age on Screening for Hyperactive/Impulsive Presentations of ADHD.

OBJECTIVE: This study aims to quantify the potential age bias in screening of hyperactive/impulsive presentations of ADHD in children ages 5 to 12 through comparison of age-based and overall percentiles in screening. METHOD: A referred clinical sample of 307 children ages 5 to 12 with behavioral concerns completed the Vanderbilt Attention Deficit-Hyperactivity Disorder Diagnostic Parent Rating Scale (VADPRS) and were formally evaluated for ADHD with a diagnostic interview. Analysis utilizing logistic regression and receiver operating characteristic (ROC) curves was performed to compare the screening performance of agebased and overall percentiles. RESULTS: The age-based percentiles demonstrated no improvement in the analyzed models compared to overall percentiles in hyperactive presentation ADHD screening. This finding was present in the overall sample and in the sub analysis of the 5 to 6 year old children. CONCLUSIONS: This study identifies no improvement in modeling of hyperactive/impulsive ADHD screening when considering a child's age using age-based percentiles.

Meta-analysis of associations between childhood adversity and diurnal cortisol regulation.

Childhood adversity has been associated with hypothalamic-pituitary-adrenal axis dysregulation, which is associated with mental and physical health consequences. However, associations between childhood adversity and cortisol regulation in the current literature vary in magnitude and direction. This multilevel meta-analysis examines the association between childhood adversity and diurnal cortisol measures, as well as potential moderators of these effects (adversity timing and type, study or sample characteristics). A search was conducted in online databases PsycINFO and PubMed for papers written in English. After screening for exclusion criteria (papers examining animals, pregnant women, people receiving hormonal treatment, people with endocrine disorders, cortisol before age 2 months, or cortisol after an intervention), 303 papers were identified for inclusion. In total, 441 effect sizes were extracted from 156 manuscripts representing 104 studies. A significant overall effect was found between childhood adversity and bedtime cortisol, r = 0.047, 95% CI [0.005, 0.089], t = 2.231, p = 0.028. All other overall and moderation effects were not significant. The lack of overall effects may reflect the importance of the timing and nature of childhood adversity to adversity's impact on cortisol regulation. Thus, we offer concrete recommendations for testing theoretical models linking early adversity and stress physiology.

Deficits in Parent Knowledge of Behavior Management Skills is Strongly Associated with CD Symptoms but Not ODD Symptoms.

We conducted secondary analyses of existing data to examine the association between parent scores on the Knowledge of Effective Parenting Test (KEPT) and child symptoms of Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Parent knowledge of behavior management skills and child behavior symptoms were assessed in a nationally representative sample of parents/guardians (N = 1,570) of children aged 5-12 from all 50 states. Results showed consistent and robust correlations between parent knowledge of behavior management skills and CD symptoms but not ODD symptoms. These findings suggest that parent knowledge of behavior management may be a greater risk factor for CD than ODD, with implications for taxonomy and understanding the etiology of these two disorders. We also discuss the implications of these findings for the prevention and treatment of these two disorders which are often grouped together in treatment trials.

Objective Measurement of Hyperactivity Using Mobile Sensing and Machine Learning: Pilot Study.

BACKGROUND: Although hyperactivity is a core symptom of attention-deficit/hyperactivity disorder (ADHD), there are no objective measures that are widely used in clinical settings. OBJECTIVE: We describe the development of a smartwatch app to measure hyperactivity in school-age children. The LemurDx prototype is a software system for smartwatches that uses wearable sensor technology and machine learning to measure hyperactivity. The goal is to differentiate children with ADHD combined presentation (a combination of inattentive and hyperactive/impulsive presentations) or predominantly hyperactive/impulsive presentation from children with typical levels of activity. METHODS: In this pilot study, we recruited 30 children, aged 6 to 11 years, to wear a smartwatch with the LemurDx app for 2 days. Parents also provided activity labels for 30-minute intervals to help train the algorithm. Half of the participants had ADHD combined presentation or predominantly hyperactive/impulsive presentation (n=15), and half were in the healthy control group (n=15). RESULTS: The results indicated high usability scores and an overall diagnostic accuracy of 0.89 (sensitivity=0.93; specificity=0.86) when the motion sensor output was paired with the activity labels. CONCLUSIONS: State-of-the-art sensors and machine learning may provide a promising avenue for the objective measurement of hyperactivity.

National Norms for the Vanderbilt ADHD Diagnostic Parent Rating Scale in Children.

OBJECTIVE: To provide national norms and percentiles for both research and clinical scoring modalities of the Vanderbilt Attention Deficit/Hyperactivity Disorder (ADHD) Diagnostic Parent Rating Scale (VADPRS) for a representative sample of children ages 5-12 in the United States. METHOD: The five clinical subscales of the VADPRS were completed by 1,570 caregivers of children ages 5-12 in the United States, with children representative of the national population on key demographic variables including race, sex, ethnicity, family income, and family educational level. Descriptive statistics and measures of internal consistency of both dimensional and symptom count scoring were provided for each of the five clinical subscales of the inventory, as well as percentiles and group comparisons for select dimensional scoring subscales based on age and child sex. RESULTS: Measures of internal consistency for each subscale using both scoring modalities of the VADPRS ranged from high to acceptable. There were statistically significant differences among the different subscales for both age (ADHD hyperactivity, anxiety/depression) and sex [both presentations of ADHD, oppositional defiant disorder (ODD)] for the total sample. These differences, however, were modest in magnitude and unlikely to be clinically meaningful. CONCLUSIONS: This study enhances the research and clinical utility of the VADPRS by providing national norms and percentiles for each of its subscales. Differences between age and sex across the sample were statistically significant for two of the subscales (Hyperactivity and Anxiety/Depression) with additional subscales significant for sex alone (Inattentive and ODD), but these differences were not substantial enough to indicate a need for separate cut-offs for screening purposes.

Regulating digital therapeutics for mental health: Opportunities, challenges, and the essential role of psychologists.

With so many promising digital therapeutics for anxiety and obsessive-compulsive (OC) spectrum problems, there is an urgent need to consider how evolving regulatory oversight of digital therapeutics is poised to shift how these tools are developed, evaluated, reimbursed, and delivered. In this commentary, we discuss both opportunities and potential pitfalls associated with emerging government regulations of digital therapeutics for mental health, and we consider how applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine and limit the broad accessibility of these software-based innovations that have been explicitly designed to expand the accessibility of care. For example, the vast majority of behavioural and mental health providers do not have 'prescription privileges' (a term originally rooted in pharmacologic practices), and as a result, under current regulations in the U.S. would not be authorized to make FDA-cleared digital therapeutics available to their patients. This is particularly concerning given that most digital therapeutics for mental health are directly rooted in psychological and behavioural science, yet psychologists would not be authorized to incorporate these innovations into their practice. We consider how synchronizing regulatory standards across countries may prove useful, and we conclude by arguing that multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the discipline and practice of psychology. PRACTITIONER POINTS: Emerging government regulations of digital therapeutics for mental health present both opportunities and potential pitfalls Applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine the broad accessibility of these software-based innovations. Synchronizing regulatory standards across countries may prove useful. Multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the field of psychology.

Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study.

BACKGROUND: Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents' and parents' reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments. OBJECTIVE: This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW. METHODS: We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups. RESULTS: We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions. CONCLUSIONS: We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW.

National Norms and Correlates of the PHQ-8 and GAD-7 in Parents of School-age Children.

Anxiety and depressive disorders are global public health concerns, and research suggests that these disorders are common in parents and can adversely influence family functioning. However, little is known about normative levels of anxiety and depressive symptoms in parents of school-age children. The present study reports on generalized anxiety and depressive symptoms in 1570 parents and guardians of a nationally representative sample of children ages five to twelve years using two widely used and validated questionnaires: the eight-item variant of the Patient Health Questionnaire depression scale (PHQ-8) and the seven-item Generalized Anxiety Disorder scale (GAD-7). Moderate to severe levels of generalized anxiety symptoms were reported in 12.7% of the total sample and moderate to severe levels of depressive symptoms were reported in 14.1% of the sample; 17.7% of the sample reported moderate to severe levels of either generalized anxiety or depressive symptoms. This percentage was higher for females, younger parents and guardians, and parents and guardians reporting lower household incomes. These data, collected online in early 2018, may be useful for researchers and clinicians studying and treating anxiety and depression in parents. Further, these data provide a baseline for researchers currently studying the impact of changes related to the novel coronavirus (COVID-19) pandemic (e.g., school closures) on the mental health of parents of school-age children.

Development and Validation of the Parenting Skill Use Diary (PSUD) in a Nationally Representative Sample.

Objective: We describe the development and psychometric properties of an instrument designed to assess the use of effective parenting skills reported with a daily diary. The Parenting Skill Use Diary (PSUD) was developed iteratively relying on a "common elements" approach to quantify the use of evidence-based parenting techniques for responding to child misbehaviors and positive behaviors.Method: The PSUD was administered online daily for seven days to parents/guardians of children aged 5-12. The nationally representative sample (N = 1,570) was selected to match the US population of such parents/guardians on key demographic variables.Results: The instrument demonstrated the ability to capture significant between person variability in the appropriate use of parent management skills. A weekly summary score discriminated between parents/guardians whose children screened positive versus negative for Conduct Disorder (AUC = .72) and Oppositional Defiant Disorder (AUC = .70).Conclusions: The results supported the reliability of validity of the diary as a research tool for examining mean differences.

Adult processing of child emotional expressions: A meta-analysis of ERP studies.

Numerous event-related potential (ERP) studies have examined adults' neural responses to child emotional expressions to understand the neurobiological mechanisms contributing to caregiving. It is unclear, however, whether one emotion evokes an enhanced response across components, and whether this pattern differs based on parent status or other sample characteristics. This meta-analysis quantified adult responses to child emotional expressions at the N170 and the late positive potential (LPP) components. Cohen's d reflected the difference between crying and neutral (CN), crying and laughing (CL), and laughing and neutral (LN) N170 and LPP amplitudes. Crying expressions elicited slightly enhanced N170 and LPP amplitudes relative to neutral and laughing expressions (N170 CN: k = 24, d = -0.09, p < 0.001; N170 CL: k = 30, d = -0.07, p = .004; LPP CN: k = 20, d = 0.12, p = .027; LPP CL: k = 27, d = 0.10, p < .001), and laughing expressions elicited slightly enhanced N170 amplitudes relative to neutral expressions (N170 LN: k = 21, d = -0.05, p = .02). Parental status, child age, risk factors for insensitive caregiving, and measurement characteristics moderated some effect sizes, with reference electrode emerging as the most consistent moderator. Results shed light on the typical pattern of neural response to child emotions and characteristics that may moderate this response. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Workforce Turnover in Community Behavioral Health Agencies in the USA: A Systematic Review with Recommendations.

Rates of behavioral health workforce turnover are chronically high, with detrimental effects on the agency and remaining staff, as well as hypothesized negative impacts on client care and outcomes. Turnover also creates challenges for studies investigating the effectiveness and/or implementation of behavioral health interventions. Research examining factors that precede and predict behavioral health staff turnover has become increasingly important, as have studies that include recommendations for preventing and reducing turnover. The current paper systematically reviews the body of research on factors associated with behavioral health staff turnover, synthesizes recommendations made for combating turnover, and identifies gaps in this important area of research.

A Computer Adaptive Test (CAT) for knowledge of parent management skills: Prototype development and preliminary psychometrics.

The Knowledge of Effective Parenting Test (KEPT) is a measure of parent management skills that was developed as an outcome measure for clinical trials of psychosocial treatments for disruptive behavior disorders. In the current study, we developed a computer adaptive test (CAT; KEPT-CAT) prototype and compared it to the full item bank (21 items; KEPT-Full) and to a brief static version (10 items; KEPT-Brief) using simulations from a large (N = 1,570) nationally representative dataset. Results showed that the KEPT-CAT prototype (median = 8 items) was slightly more efficient than the KEPT-Brief and had a significantly higher (p < .001) correlation with scores from the full item bank (r = .97) than the KEPT-Brief (r = .94). The KEPT-CAT prototype has additional advantages over the static KEPT-Brief, including the potential selection of different items from one administration to the next. This flexibility can reduce practice effects that might result from repeated administration of the same fixed items. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders.

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%-50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9-14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.

Psychometric Properties of the SCARED in a Nationally Representative U.S. Sample of 5-12-Year-Olds.

OBJECTIVE: To examine the factor structure of the Screen for Child Anxiety Related Emotional Disorders - Parent Report (SCARED-P) in young children and elucidate normative levels of parent-reported anxiety using a nationally representative sample of parents of children ages 5-12 years living in the United States. METHOD: The 41-item SCARED-P was administered to parents of 1,570 youth who were selected to match the U.S. population on key demographic variables. SCARED-P model fit and mean score differences by age, race/ethnicity, and sex were assessed. RESULTS: SCARED-P model fit and subscale reliability appeared almost identical in younger children (ages 5-8) and older children (ages 9-12), although model fit for a five-factor model was poor in both groups. Symptoms of generalized anxiety increased from age 5 to 12, while symptoms of separation anxiety disorder decreased. Parents reported significantly more symptoms of social anxiety in females than males. No significant differences by race/ethnicity were found for mean levels of anxiety or model fit. CONCLUSIONS: The SCARED-P shows some utility as an anxiety screening instrument in a representative sample of U.S. youth as young as 5-years-old, but caution should be used when interpreting subscale scores.

The Importance of Calibration in Clinical Psychology.

Accuracy has several elements, not all of which have received equal attention in the field of clinical psychology. Calibration, the degree to which a probabilistic estimate of an event reflects the true underlying probability of the event, has largely been neglected in the field of clinical psychology in favor of other components of accuracy such as discrimination (e.g., sensitivity, specificity, area under the receiver operating characteristic curve). Although it is frequently overlooked, calibration is a critical component of accuracy with particular relevance for prognostic models and risk-assessment tools. With advances in personalized medicine and the increasing use of probabilistic (0% to 100%) estimates and predictions in mental health research, the need for careful attention to calibration has become increasingly important.

Development and validation of the Knowledge of Effective Parenting Test (KEPT) in a nationally representative sample.

We report on the development and psychometric properties of an instrument for the assessment of knowledge of effective parenting skills specific to conduct problems using an item response theory (IRT) framework. The initial item pool (36 items) for the Knowledge of Effective Parenting Test (KEPT) was administered online to a national sample (N = 1,570) selected to match the U.S. population on key demographic variables. Items with strong psychometric properties and without significant differential item functioning (DIF) by race/ethnicity were retained, resulting in a 21-item version of the KEPT with excellent reliability and validity. We also created a brief 10-item version of the KEPT to reduce respondent burden and to enhance its utility for repeated measurement in longitudinal and intervention research. We report norms and percentiles for both the 21-item version (KEPT-Full) and the 10-item version (KEPT-Brief). (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evidence-Based Assessment from Simple Clinical Judgments to Statistical Learning: Evaluating a Range of Options Using Pediatric Bipolar Disorder as a Diagnostic Challenge.

Reliability of clinical diagnoses is often low. There are many algorithms that could improve diagnostic accuracy, and statistical learning is becoming popular. Using pediatric bipolar disorder as a clinically challenging example, we evaluated a series of increasingly complex models ranging from simple screening to a supervised LASSO regression in a large (N=550) academic clinic sample. We then externally validated models in a community clinic (N=511) with the same candidate predictors and semi-structured interview diagnoses, providing high methodological consistency; the clinics also had substantially different demography and referral patterns. Models performed well according to internal validation metrics. Complex models degraded rapidly when externally validated. Naïve Bayesian and logistic models concentrating on predictors identified in prior meta-analyses tied or bettered LASSO models when externally validated. Implementing these methods would improve clinical diagnostic performance. Statistical learning research should continue to invest in high quality indicators and diagnoses to supervise model training.

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial.

BACKGROUND: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). OBJECTIVE: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. METHODS: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. RESULTS: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). CONCLUSIONS: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment.