The Clear Fear app powered by stem4 provides ways for children and young people to manage symptoms of anxiety. Developed by Dr Nihara Krause, a Consultant Clinical Psychologist, together with ideas from young people, Clear Fear uses a Cognitive Behavioural Therapy (CBT) framework to help change anxious thoughts and emotions, alter anxious behaviours and calm fear responses.
The app also has helpful descriptions of the different ways in which anxiety shows, resources and a ‘grit box’ to boost resilience.
It is not a substitute for a mental health professional.
Clear Fear is recommended for the ages of 11-19 years. Younger users can work on several of the tasks with the assistance and support of a parent/carer or teacher.
‘The fear of threat or anxiety is like a strong gust of wind, it drags you in and makes you want to fight it or to run away. Instead, face your fear, reduce the threat and glide.’
Clear Fear uses a Cognitive Behavioural model developed by a clinician in collaboration with Children and Young People (CYP). Cognitive Behavioural Therapy (CBT) is an evidence-based treatment to help anxiety disorders and is the first line treatment recommended by NICE.
The app helps users to overcome their anxiety symptoms by learning to regulate their physiological responses through graded relaxation and breathing, by learning to challenge unhelpful styles of thinking through exercises, and overcome behavioural elements of anxiety disorders such as avoidance in social anxiety and phobias, or over-checking in obsessive-compulsive disorder by inviting them to complete increasingly challenging interactions that the user generates themselves for their environment.
There is also the opportunity for emotional expression, self-monitoring, resilience building and helpful resources. An immediate help section is available if the user is suffering from panic attacks, which helps them to develop a ‘safety net’ – a support network of thoughts, behaviours and contacts.
For those with severe symptoms of anxiety Clear Fear can be used in conjunction with a mental health professional. Whilst CBT underpins the app together with user-friendly ways to target each area, Clear Fear has been developed co-collaboratively with young people, clinicians and teachers. Clear Fear is password-protected and confidential.
Clear fear offers a selection of tasks, based on CBT and other evidence-based approaches that have been shown to reduce symptoms of anxiety. Tasks are accomplished in the following ways:
Goal setting and Behavioural experiments
Exposure based challenges form the foundations in CBT. Clear Fear includes behaviour change techniques such as identifying specific goals, tailoring each goal to suit each individual, barrier identification, breaking long term goals into short term challenges, accomplishing easier challenges first, prompts/cueing, reinforcing success, social support and tracking personal information to enhance self-directed learning.
These include identifying three common types of automatic negative thoughts together with self-monitoring, seeking evidence and restructuring thoughts. Therapeutic gains may include symptom relief and an increased sense of control over anxiety through its objectification.
Mindfulness based exercises are available in both visual and auditory format to improve low self-esteem, emotional reactivity and improved functioning (Goldin and Gross 2010).
Emotional expression and regulation
Clear Fear provides children and young people with the opportunity to express their emotions through note keeping, find alternative ways of emotional regulation through a range of tasks, or to substitute negative emotions for positive ones through the use of humour or by selecting provided gifs.
Psycho-education is provided in the information section as well as in optional notifications sent to users in order to support their momentum in reaching personal goals, guiding them through the application as well as providing valuable psychological insights. Among the suggestions provided will be information on formulating and setting realistic goals, overcoming fears and increasing motivation. Once a goal has been achieved a message may be sent to the user outlining a plan on how to maintain the new skills and avoid falling back into old habits.
Information about anxiety
Clear Fear sends messages to the user to normalise their experience of anxiety, provides information on the value and functioning of anxiety, and links information about specific anxiety.
Children and young people using clear fear will are encouraged to write notes about their experiences after they complete a challenge. This will deepen their understanding of what has occurred.
Based on the concept that ‘grit’ is a necessary factor in resilience, Clear Fear contains a range of motivational statements, positive quotes, information on resilient and inspirational people generated by young people.
Provides containment of anxiety for the user, whilst the Worry Ladder helps the user prioritise anxieties together with problem-solving.
The monitoring section includes and anxiety profile and anxiety tracker to help the user self-monitor across every task. Therapeutic gains may include increased self-reflection and understanding, feelings of hope and increased control and confidence on the ability to regulate anxiety symptoms and a reduction in secondary anxiety. Reviewing levels of anxiety helps make anxiety feel less threatening and therefore more manageable. Learning what is a helpful strategy will also become clearer.
14 young people attending a psychology service with moderate symptoms of anxiety were given Clear Fear to use alongside standard CBT treatment. They were assessed at baseline and given two screening questionnaires and their attitude to app use assessed. The screening questionnaires were the Beck Anxiety Inventory for Youth (BAI-Y; Beck et al 2001) and the Strengths and Difficulties Questionnaire. The app was used in between treatment sessions for four weeks.
Acceptability (wanting to use the app) was 100%, Reported help with reducing anxiety symptoms after each use 96%. Overall statistically significant reduction in anxiety levels. The most popular category was ‘dealing with your emotions’ and ‘safety net’ followed by immediate help, information on anxiety types.
Whilst this is a non-control pilot study with a very small sample size, the benefits of having an ‘at hand’ prompt and support were highly valued by the young people who felt that they could both consolidate what they were learning in terms of anxiety management as well as have a ‘personal companion’ in terms of the app to help manage their symptoms. In addition, they were very positive about the fact that the app came from a scientific source and their parents were equally supportive of the fact that this could be a prompt they could use to benefit their children.
A clinical study is pending – we are currently having discussions with two potential research organisations.
Analytics from the app:
In order to evidence the effectiveness of the app, the following data is collected:
As of 1 April 2019:
Clear Fear has been downloaded over 23,000 times.
93% of Clear Fear users reported that activities reduced their anxiety.
We worked co-collaboratively with young people to develop Clear Fear. The co-collaborative workshops with young people explored desired outputs, user journeys, visual concepts, security/privacy, user experience, and tone of voice.
Our young people user groups did not want chatbot technology on the basis it may deter someone who was anxious from seeking real professional help, they felt a real person worked better for anxiety and they did not feel their parents would be comfortable with not technology that learned their individual response patterns. User feedback also meant we changed the setting of a password to a passcode.
The clinical and professional groups provided input on safety, user characteristics, strengths, potential barriers, referrer experience, the tone of voice, teacher and parent voice.
Content for the grit box has been obtained from groups of students attending stem4 school conferences.
The clinical content of Clear Fear was created by a Clinical Psychologist and the app underwent a clinical safety assessment with a range of clinicians including a GP, Adolescent Psychiatrist, A&E doctor, school nurses, and Clinical Psychologists.
stem4 consistently monitors user feedback via emails, social media and reviews on the App Store/Google Play.
Clear Fear is reviewed and updated every three months to ensure the app is clinically valid.
The clinical risk is monitored and laid out in the hazard log and map to the DCB 0129 guidelines. A flow chart of hazard mitigation and response is available. This outlines how issues will be addressed together with target response times.
Our target response time for urgent issues is 24 hours, for high priority issues 72 hours, medium priority 7 working days and low priority 14 working days.
Clear Fear does not collect any personally identifiable information. Anonymised data is collected to ensure the effectiveness of the app can be monitored.
Clear Fear is an app which can be used on IOS, Android or tablets/laptop devices. The content is downloaded the first time the user opens the app and then cached. It can still be viewed and used offline, with the exception of the Laugh and Smile section with animated gifs do require web access.
App data is stored using Amazon Web Services (AWS) which has certification for compliance with ISO 27001:2013 – https://d1.awsstatic.com/
Clinical risk is managed by having a contractual agreement with the developer that data security and technical risks will be addressed at every update or when concerns are raised via the clinical safety system which indicates clear timeframes and the flow of what action will be taken.
The app is stand-alone and does not interact with existing enterprise systems.
It has been designed with young people to ensure data and device memory/data use in their preferred device (smartphone) is not compromised.
Activity is logged to present the user with the following information:
In order to evidence the effectiveness of the app, the following data will be made available:
To report an issue with Clear Fear please email firstname.lastname@example.org.
stem4 endeavour to respond to the enquirer according to our target response times. Risk will be amended with immediate effect. Amendments to the workings of the app will be made at every update.
NHS Digital DCB0129 standards.
Also our app developers:
We also do strive to be as broadly accessible as possible through the use of industry best practices. For example, contrast colours for those with sight issues, using a font that’s clear to read etc.