Digital interventions could transform routine care but we need more research on how to achieve this

Digital interventions, also known as Internet interventions or eHealth interventions, are available for children, adolescents and their families. They can be used for various purposes, employ a wide range of technology, be interactive and be based on theory and evidence. Interventions can either stand alone as self-help tools or involve contact with a health professional. In this issue of Acta Paediatrica, Størksen et al.1 provide a scoping review of Internet-based interventions for parents of children aged 0–5 years. They found 237 papers published between January 1999 and January 2018, including digital interventions for autism spectrum disorders, general parenting support, obesity and respiratory diseases. The authors concluded that more research is needed outside English-speaking countries and make recommendations about designing interventions and reporting results. I agree with these points, but I also believe that an equally, or more, relevant issue is to get more high-quality interventions for children and families into clinical practice. The demand for prevention, treatment and rehabilitation is considerable and it may be impossible to meet it. Furthermore, how would we evolve as a species if everyone got the treatment and rehabilitation they needed, without delay, knew how to live reasonably healthy lives and were not anxious and sad due to traumas and adversities? Heckman suggested that administering preventative interventions to pre-school children is likely to achieve the greatest potential gain.2 It is unlikely that increases in health professionals would keep pace with this demand, as many countries already have shortages. The growing scientific field of digital interventions may help to saturate this demand. People already use the Internet and digital devices for health purposes, as they are easily available. Størksen et al. noted a marked increase in digital interventions for the parents of young children since 2012 and the general digital health field is rapidly expanding. Digital interventions can deliver higher quality care and support because they can include state-of-the-art treatment in specialised fields. They can also remove the constraints of consultation times and everyone with an Internet connection can access the same treatment, anytime and anywhere. Not least, they are available when human professionals are not. Some people are still skeptical about using digital interventions for healthcare purposes and may base their resistance on a few counterarguments. The first is that people need people, not technology. Well, that is not true, historically. Latour maintained that humans have always developed and integrated new technology,3 like the typewriter, calculator, computer and telephone. Digital interventions for healthcare are just the next step and not that different. The second is that when it comes to treatment and support, humans are still best. However, as far back as 2008, Barak et al.4 reported that, on average, digital interventions could be equally as effective as face-to-face therapy. The third is that some needs are best met by people and that is true. On the other hand, my own research suggests that there may also be times where digital interventions are superior.5, 6 The fourth is that digital interventions may only be effective for people with milder symptoms. In a 2020 review of meta-analyses of digital interventions for children and adolescents, one meta-analysis that was included found that the severity of symptoms moderated the treatment effects for anxiety, but not for depression.7 Certainly, digital interventions will not be helpful for everyone, but they are cost effective and accessible for those they do help. Clearly, you do not have to be a young techno-enthusiast to acknowledge that it is rational to harness the potential of digital interventions. Although the field of digital interventions is growing, I believe that there are three reasons why their implementation in routine clinical care remains limited. One challenge is the narrow focus of interventions and the fact that research produces too few high-quality interventions that can be broadly adopted. Research is dominated by randomised controlled trials on the effects of specific interventions for a specific health issue for a specific population. These interventions are usually tested as total packages, without knowing how they achieve their effect. Størksen et al.1 call for more effect studies, but I believe that these are now less important. We know that digital interventions can work well for a range of purposes. The question is how the best interventions achieve their effect. Over a decade ago, Webb et al.8 warned that we know too little about how digital interventions work to consistently devise high-quality new ones. Unfortunately, this knowledge is still lacking. We need research that explains how digital interventions work, who they work for and in what circumstances. This would be of great benefit to the children and families who could be helped by these tools. The second challenge is that the lack of infrastructure between research and clinical practice produces too many dead-end projects. Interventions that show promising effects at the research stage may only be implemented locally and for as long as research funding lasts. This means that few high-quality interventions are permanently available for health professionals to use in their practice. There should be systems that ensure that digital interventions developed for research purposes can be implemented into routine care by other stakeholders. Luckily, a Dutch initiative called Open Digital Health is working to establish a library of digital interventions that others can use or adapt. Until this library, or other alternatives, are in place, clinicians may volunteer for research projects or seek out national initiatives. They may also consider helping patients to use publicly available apps. For example, the Enlight assessment tool, developed by Baumel et al.,9 can help with quality judgements. The final challenge is the need for more detailed assessments of the best ways for digital interventions to fit into the larger system of care. Størksen et al.1 call for research to determine whether digital interventions work better when they are combined with human support, but the question goes beyond that. For example, it is also possible that professional relationships work better when they are combined with digital tools. Chute et al. found that patients wanted digital interventions that could be used to improve communication with health professionals, for example helping them to tell their story only once and visualising personal or clinical data.10 Research is needed to define the parameters, so that we can optimise the use of digital interventions within the health care system. Digital interventions could, and should, play a role in the evolution of our welfare systems. They need to adapt to our accumulating knowledge of people as complete mind–body beings, embedded in social systems and with the power to influence their own and other's health and well-being. These evolved systems of integrated traditional and digital care may be particularly beneficial for children and adolescents who may find it difficult to relate to, and trust, new people. A digital tool could make it easier for them to make their voice heard and thus improve their care. The scoping review by Størksen et al.1 in this issue highlights the plethora of digital interventions and the researchers who are waiting for the chance for their developments to be integrated into routine paediatric care. Clinicians, researchers, politicians and other stakeholders should try to find solutions to the challenges that currently stand in the way of digital interventions transforming clinical practice. None.