The Clear Fear app 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, the Clear Fear app uses a Cognitive Behavioural Therapy (CBT) framework to help change anxious thoughts and emotions, alter anxious behaviours and calm fear responses.
The Clear Fear app also has helpful descriptions of the different ways in which anxiety shows, resources and a ‘grit box’ to boost resilience.
The Clear Fear app is a self-guided tool that uses an evidence-based treatment approach called Cognitive Behavioural Therapy (CBT). It is not a substitute for the assessment and treatment of a mental health professional.
The Clear Fear app 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.’
The Clear Fear app 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 the National Institute for Health and Care Excellence (NICE).
The Clear Fear app helps users to manage anxiety symptoms by learning to regulate physiological responses through graded relaxation and breathing; to challenge anxious styles of thinking; and overcome behaviours associated with anxiety disorders such as avoidance in social anxiety and phobias and over-checking in obsessive-compulsive disorder.
There are also opportunities for emotional expression through journaling and self-monitoring through progress graphs. An Immediate Help section is available to help manage extreme anxiety or feelings of panic. Each user is encouraged to set up a ‘safety net’ when they download the Clear Fear app, which provides an opportunity to note anxiety-reducing thoughts and coping behaviours as well as list helpful contacts.
For those with severe symptoms of anxiety, the Clear Fear app can be used in conjunction with a mental health professional. Whilst Cognitive Behavioural Therapy (CBT) underpins the Clear Fear app, the app has been developed co-collaboratively with young people and clinicians. The Clear Fear app is password-protected and confidential.
The Clear Fear app offers a selection of tasks, based on Cognitive Behavioural Therapy (CBT) and other evidence-based approaches that have been shown to reduce symptoms of anxiety (references available below). Tasks are accomplished in the following ways:
Goal Setting and Behavioural Experiments
Exposure based challenges form the foundations of Cognitive Behavioural Therapy (CBT). The Clear Fear app 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.
Strategies to Reduce Physiological Responses
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
The Clear Fear app 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 Clear Fear app as well as providing valuable psychological insights.
Among the suggestions provided are opportunities to learn to set realistic goals, overcome fears and increase motivation.
Information about Anxiety
The Clear Fear app provides information on the different ways in which anxiety may present, provides in-app task suggestions to help as well as books and resources.
Based on the concept that ‘grit’ is a necessary factor in resilience, the Clear Fear app contains a range of motivational statements, positive quotes, information on resilient and inspirational people generated by young people.
Dealing With Worries
The Worry Box provides containment of anxiety for the user, whilst the Worry Ladder helps the user prioritise anxieties together with problem-solving.
The monitoring section includes an 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 in 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.
National Institute of Clinical Excellence (NICE) guidelines – Anxiety disorders: recognition, assessment and treatment in children and young people, 2013
Seligman, L.D and Ollendick, T H (2011) Cognitive Behaviour Therapy for Anxiety Disorders in Youth, Child Adolesc Psychiatr Clin N Am. 2011 Apr; 20(2): 217–238. doi: 10.1016/j.chc.2011.01.003
Anxiety and anxiety disorders have increased considerably as a result of the pandemic. In order to support children and young people affected, stem4 has created an animated video and user booklet on how to use the Clear Fear app. This includes specific anxieties that may have increased during the pandemic, for example, health-related anxiety or obsessive-compulsive symptoms and also outlining pandemic safe tasks which abide by safety guidelines such as social distancing.
The Clear Fear app use has increased by 40% subsequent to the pandemic and stem4 will endeavour to use the feedback we receive from our users and our focus groups to update the app.
To develop an evidence-based, widely accessible digital tool to help children and young people (age 11-19) manage their anxiety symptoms (younger with parent involvement). This includes reducing the intensity of anxiety symptoms, reducing the frequency of anxiety symptoms and helping identify underlying trigger factors together with learning alternative positive coping strategies.
To devise an anonymised analytical model to evidence effectiveness and inform future development.
To comply with NHS information governance requirements.
To raise the profile of stem4 and its work to support teenage mental health.
14 young people attending a psychology service with moderate symptoms of anxiety were given the Clear Fear app to use alongside standard Cognitive Behavioural Therapy (CBT) treatment. They were assessed at baseline and given two screening questionnaires and their attitude to the Clear Fear 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 Clear Fear app was used in between treatment sessions for four weeks.
Acceptability (wanting to use the Clear Fear 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 Clear Fear app to help manage their symptoms. In addition, they were very positive about the fact that the Clear Fear 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 to evidence the Clear Fear app effectiveness is currently being carried out. Having received ethical committee (IRAS) approval in 2020 the study is being carried out by Informed Thinking, an impartial clinical research organisation for stem4. The research is part-funded by stem4 and a Nominet #RESET grant.
This quantitative and qualitative study uses questionnaire, interview and observational approaches to evidence symptom change in 50, 16-21 year-olds, monitoring symptoms over a 9 week period to compare pre and post measures of anxiety together with a range of other measures including their evaluation of the Clear Fear app features and usability. A peer-review paper will be prepared and submitted subsequent to the completion of the study.
As a result of the pandemic, it is estimated that this study will take around 12-15 months to complete or as soon as we are able to recruit the full sample. If you are interested in taking part in the survey and fit the eligibility criteria, please visit our study page or contact firstname.lastname@example.org.
Analytics from the Clear Fear app:
In order to evidence the effectiveness of the Clear Fear app, the following data is collected:
All analytics collected are non-identifiable with users since we do not collect any identifiable data.
Latest Clear Fear app analytics data (up until the end of December 2020) tells us:
There have been over 450,000 downloads of the Clear Fear app to date.
93% of the individuals who used the Clear Fear app reported that an activity helped to reduce their anxiety.
The Clear Fear app was developed co-collaboratively with young people. Co-collaborative workshops with young people explored desired outputs, user journeys, visual concepts, security/privacy, user experience, and tone of voice.
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.
stem4 consistently monitors user feedback via emails, social media and reviews on the App Store/Google Play. In addition, we use annual, small user groups to feedback to update the Clear Fear app.
Over the pandemic, an animated video and booklet were created providing Clear Fear app users with guidance on how to use the app safely. The content for this was created by a clinical psychologist together with feedback from a small group of users.
We aim for all our user groups to be diverse and inclusive and represent a cross-section of our youth user community.
Clinical Input and Safety
The clinical content of the Clear Fear app 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.
Our clinical evaluation groups also include a diverse range of different professionals.
We welcome user feedback which can be emailed to email@example.com.
A number of standards were used. These included:
NHS Digital DCB0129 standards. Developed by the NHS, this standard is designed to help manufacturers of health IT software evidence the clinical safety of their products.
User Needs design based on workshop feedback with young people.
Design with data using existing app data.
Iteration – New updates depending on things that have (or haven’t) worked or new functionality.
stem4 strives 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.
stem4 has put a number of measures in place to ensure that the Clear Fear app is clinically safe to use.
The Clear Fear app has been developed by a Consultant Clinical Psychologist and validated by the group it is for. The Clear Fear app complies with the clinical safety standard DCB0129. Developed by the NHS, this standard is designed to help manufacturers of health IT software evidence the clinical safety of their products.
stem4 has a Clinical Risk Management Plan. A Clinical Safety Review with clinical professionals was undertaken for the Clear Fear app and a Clinical Safety Case Report and Hazard Log created. The clinical risk is monitored and laid out in the Hazard Log. A flow chart of hazard mitigation and response is available which outlines how issues will be addressed together with target response times.
The 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.
The Clinical Safety Officer (CSO) is Dr Nihara Krause.
stem4 consistently monitors user feedback via emails, social media and reviews on the App Store/Google Play.
The Clear Fear app is reviewed on a quarterly basis during which app efficacy, including the efficacy of the activities, is reviewed, and the app updated as necessary to ensure it is clinically valid.
The Clear Fear app is reviewed every three months and updated as required.
The Clear Fear app is an app which can be used on iOS and Android devices. The content is downloaded the first time the user opens the Clear Fear app and then cached. It can still be viewed and used offline, with the exception of the Laugh and Smile section with animated gifs that do require web access.
The Clear Fear app has been designed with young people to ensure data and device memory/data use in their preferred device (smartphone) is not compromised.
The Clear Fear app does not collect personally identifiable data and an account does not need to be created to use the Clear Fear app. No cookies are used. IP addresses are not captured. The Clear Fear app is standalone and does not connect to any other apps or devices or interact with existing enterprise systems.
Some optional questions are asked in the Clear Fear app. This information is only used for research purposes and is completely anonymous. Anonymised data on whether activities helped is collected to ensure that we can monitor the effectiveness of the Clear Fear app and individual activities.
Clear Fear app users can be reassured that all information that is noted information including the contacts in the Safety Net are completely private. stem4 has no access to any of this information.
In order to evidence the effectiveness of the Clear Fear app, the following data will be made available:
Activity is logged to present the user with the following information:
All optional question and activity feedback data collected via the Clear Fear app is aggregated and cannot be tracked to each user/device. However, the security of this data is still important to us and we will take all steps reasonably necessary to ensure that the data is treated securely. The transfer of data is encrypted over a secure connection (SSL).
Clear Fear app data is stored using Amazon Web Services (AWS) which has certification for compliance with ISO 27001:2013 – https://d1.awsstatic.com/certifications/iso_27001_global_certification.pdf.
This data is retained for no longer than is necessary and destroyed by 5 years after expiration.
stem4 is not required to register with the ICO (Information Commissioner’s Office) as no personal information is being processed. stem4 is compliant with the Data Protection Act 2018 and the GDPR. stem4’s nominated Data Protection Officer (DPO) is Yvette Nieslony and can be contacted at firstname.lastname@example.org.
The Clear Fear app does not create user accounts. This was based on user research, with young people telling us they valued privacy. This does mean that if you delete the Clear Fear app or change your device, that any app data will be lost. stem4, therefore, recommends that screenshots of any data that is to be saved are taken.
To report an issue with the Clear Fear app please email email@example.com providing as many details about the issue as you can. stem4 endeavours to respond to you according to our target response times. We assess and record any clinical risk. We review the Clear Fear app quarterly and make updates where necessary.
We will resolve major bugs that prevent the intended Clear Fear app functionality from working for devices and operating systems supported.
The Clear Fear app uses an evidence-based approach but it does not substitute for the assessment and treatment of a suitably qualified mental health professional. Please contact your GP or physician before use or if you are uncertain of whether the Clear Fear app is for you. As the saying goes ‘no one size fits all’ and digital approaches help some and not others.
If your anxiety remains high after each use of the Clear Fear app, please try another approach or use the Clear Fear app alongside another approach.
If you are under the age of 11, please use it with a responsible adult.
The ‘safety net’ in the Clear Fear app is a reminder for you to add tasks you can do, things you can think of and people you can contact to help you keep safe.
stem4 does not offer a counselling service. For any concerns please contact a GP and also the signposts in the Clear Fear app. In an emergency please contact 111 or 999.
“As GPs, we see a significant amount more of anxiety disorders in young children and in adolescents than we used to. The app would offer a useful evidence-based treatment and could prevent the need for referral or provide support for their first appointment.”
Dr Jeremy Harris, Senior Partner, The Groves Medical Group, BSc, MBBS, MRCGP
The Clear Fear app is ORCHA approved with a rating of 66% (iOS) and 67% (Android).
FAQ v2 16/03/21