Atlas›Domain IX · Biomedical, neuro & digital›Guide 088
Guide IX-088

NICE early-value digital therapies for children and young people

2023England
A 24 · L 70 · M 620 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: NICE early value assessment "Guided self-help digital cognitive behavioural therapy for children and young people with mild to moderate symptoms of anxiety or low mood", published 8 February 2023 as HTE3 and now listed on the NICE site as HealthTech guidance HTG660 (last updated 5 September 2023, when the evidence generation plan was added; minor population clarification October 2023). Product descriptions follow the versions in the developers' published studies: Lumi Nova (Lockwood et al., 2022), OSI (Hill et al., 2022), OSCA (Leigh & Clark, 2023), and service descriptions of SilverCloud's teen programmes. [source: NICE HTE3/HTG660]

What it is. This is not one therapy. It is a NICE decision that four guided self-help digital CBT technologies can be used as an initial treatment option for 5 to 18 year olds with mild to moderate anxiety or low mood while more evidence is collected. The four are: Lumi Nova (BfB Labs), a therapeutic game for anxiety; OSCA (Online Social anxiety Cognitive therapy for Adolescents); OSI (Online Support and Intervention for child anxiety), which is parent-led; and SilverCloud's Space from anxiety for teens, Space from low mood for teens and Space from low mood and anxiety for teens. A fifth product, ThinkNinja CBT Bytesize (Healios), was assessed but could not be used because it was awaiting CE marking. Its current status is [uncertain: not verified]. [source: NICE HTG660 recommendations and section 2]

Status (as of October 2026 per the NICE HTG660 web pages). This is an early value assessment, so it is early access and conditional:

  • Each technology may be used only after it has NHS England Digital Technology Assessment Criteria (DTAC) approval.
  • A healthcare professional must first assess the young person.
  • Regular professional support and safeguarding and risk-management processes must be in place.
  • NICE says the guidance will be reviewed within 4 years and the recommendations may change.
  • No later status change appears on the NICE pages as of October 2026.
  • DTAC status: the supplier's NHS G-Cloud listing states DTAC approval for Lumi Nova. DTAC status for OSCA, OSI and SilverCloud's teen programmes is [uncertain: not verified]; check it locally before use.

[source: NICE HTG660 resources and recommendations; G-Cloud listing for Lumi Nova]

How change is thought to happen. All four deliver CBT principles as structured self-help, with a practitioner who checks in regularly. Each product works through a different mechanism:

  • Lumi Nova uses graded exposure built on inhibitory learning: the child tests feared outcomes step by step and finds they often do not happen. [source: Lockwood et al., 2022]
  • OSI teaches parents CBT strategies to use with their child. [source: Hill et al., 2022]
  • OSCA adapts cognitive therapy for social anxiety disorder (Clark and Wells' model). It targets negative social beliefs, self-focused attention, safety behaviours and negative self-images, using video feedback and behavioural experiments. [source: Leigh & Clark, 2023]
  • SilverCloud's teen programmes provide 7 core CBT modules. [source: NICE HTG660]

For the psychotherapist, the role is usually one of four: the assessing clinician, the supporting practitioner who does the weekly check-ins, the clinician a young person is stepped up to, or a colleague working alongside a school or voluntary-sector team. [synthesis]

2. Framework

Who it is for (age limits as NICE states them).

TechnologyAgesProblemWho uses it
Lumi Nova7–12anxietychild plays; guardian supports
OSI5–12anxietyparent-led
OSCA14–18social anxietyadolescent
SilverCloud teens15–18anxiety, low mood or bothadolescent

[source: NICE HTG660 section 2]

The published OSI case series recruited 7 to 12 year olds, a narrower range than NICE's 5 to 12. Follow the age range in your local contract and the product's instructions for use. [source: Hill et al., 2022; synthesis]

Setting and staff. Assessment and treatment can take place in several settings:

  • school mental health support teams
  • single point of access teams
  • voluntary sector teams
  • children and young people's mental health services (CYPMHS)

The supporting staff vary widely. They include nurses, therapists, psychologists, psychiatrists, support workers, social workers, health visitors, school nurses and education mental health practitioners. [source: NICE HTE3 PDF]

Phases (a structure derived from NICE conditions and product descriptions [synthesis]):

  1. Identification and referral. The young person, a parent or carer, a GP, school or social care identifies the difficulty. [source: NICE HTG660 section 2]
  2. Clinical assessment. The goals are to confirm mild to moderate anxiety or low mood, check risk and safeguarding, check access (device, internet, privacy, digital confidence) and offer choice. NICE notes that children without adequate equipment, internet or privacy, or with limited computer experience, are unlikely to benefit; face-to-face CBT may suit them better. They may also choose to wait for face-to-face CBT or have it afterwards. Move on when the young person is suitable, the family has consented or assented, and a risk plan is agreed. [source: NICE HTE3 PDF]
  3. Onboarding. The professional sets up the account (for Lumi Nova, school or health staff create the profile and the guardian receives a game key by SMS), explains the parent's role and agrees the check-in schedule. [source: Lockwood et al., 2022]
  4. Active guided self-help. The young person or parent works through the content, and the practitioner checks in weekly. [source: NICE HTE3 PDF] Typical formats:
    • OSI: 8 weekly modules of about 30 minutes, each followed by a phone call of about 20 minutes. [source: Hill et al., 2022]
    • OSCA: 8 core modules in the first 2 weeks, then optional modules, over 14 weeks, with weekly 20-minute calls. [source: Leigh & Clark, 2023]
    • Lumi Nova: the evaluation period was 8 weeks, with play encouraged several times a week. [source: Lockwood et al., 2022]
    • SilverCloud teens: about 4 to 8 weeks with weekly reviews in one NHS-funded service. [source: Big Life Group]
  5. Review and outcome. Use routine measures. NICE prioritises:
    • RCADS for symptoms (parent-reported for children, self-reported for young people)
    • CAIS and SDQ for impairment
    • CHU-9D for quality of life
    • engagement, and rates of and reasons for stopping
    Move on when goals are met (discharge or relapse-prevention), or symptoms are unchanged or worse, or risk has risen (step up). [source: NICE HTE3 PDF; synthesis]
  6. Ending or stepping up. This means relapse planning and continued self-help access where the product allows it (SilverCloud self-help access for up to 12 months in one service), or referral to face-to-face CBT or CYPMHS. [source: Big Life Group; NICE HTG660]

3. Guiding principles

  • Assessment before the app. NICE requires a healthcare professional to assess each young person first. In practice: never hand out access codes without a suitability and risk assessment. [source: NICE HTG660]
  • Guided, not unsupported. These were assessed as guided self-help with regular professional support. In practice: schedule and keep weekly check-ins; do not offer the product as signposting only. [source: NICE HTE3 PDF]
  • Early, conditional status. Recommendations are made while evidence is generated and may change. In practice: tell families the evidence is still early, collect the outcome measures NICE prioritises, and recheck the product's status. [source: NICE HTG660]
  • Choice. Young people can wait for face-to-face CBT or have it after the digital treatment. In practice: present digital as one option, not a gate to other care. [source: NICE HTG660]
  • Match the product to age and problem. Each product has its own age band and target. In practice: do not use a teen product with a 12 year old, or OSCA for generalised low mood. [source: NICE HTG660 section 2]
  • Safeguarding and risk management throughout. In practice: risk is reviewed at every check-in, not only at assessment, and the stepping-up route is agreed in advance. [source: NICE HTG660; synthesis]
  • Access and equity. Equipment, internet, privacy and digital confidence matter. In practice: ask where and on what device the young person will use it, and offer face-to-face care if those are lacking. [source: NICE HTE3 PDF]
  • Neurodivergent young people. NICE notes remote delivery may suit some neurodivergent young people. It also notes that the evidence largely excluded them (the OSI and OSCA studies excluded autism). In practice: offer the product if it suits them, but monitor more closely and adapt. [source: NICE HTE3 PDF; Hill et al., 2022; Leigh & Clark, 2023]
  • Parents and carers as partners, scaled to age. The parent leads in OSI, supports out-of-game challenges in Lumi Nova, and has a smaller role for 14 to 18 year olds. In practice: agree explicitly who does what. [source: product papers; synthesis]
  • Data minimisation and transparency with minors. In practice: explain in plain words what data is collected and who sees it (for example, the professional dashboard). [source: G-Cloud listing; synthesis]
  • Report problems. NICE asks for adverse events to be reported to the MHRA Yellow Card scheme. In practice: know your service's route for this. [source: NICE HTE3 PDF]
  • The practitioner supports; the programme delivers. In practice: reinforce the programme's own model and tasks rather than running a parallel therapy, unless the young person is stepped up. [synthesis]

4. Intervention inventory

The inventory has two parts. Part A describes how each technology is delivered, as NICE and the developers' papers describe it. It stays at a descriptive level and does not reproduce programme content. Part B covers the practitioner's own tasks around the technology. Many psychotherapists will be the supporting professional; where you are not, Part B still applies to working alongside the team that is. Licensed outcome measures are named only; no items are reproduced.

A1. The NICE-defined delivery model (applies to all four)

  • Purpose: This is the frame every product must sit in for NHS use. Use it to check whether a local offer meets NICE's conditions.
  • Steps (as NICE describes it):
    1. DTAC approval from NHS England is in place before use.
    2. A healthcare professional carries out an initial clinical assessment to confirm suitability.
    3. The young person or parent works through the guided self-help with regular professional support (weekly check-ins).
    4. Safeguarding and risk-management processes are in place so that worsening symptoms are picked up quickly.
    5. The family may choose to wait for face-to-face CBT or have it afterwards.
    6. Adverse events are reported to the MHRA Yellow Card scheme.
    7. Providers have structures to review, authorise and monitor new devices.
    8. Commissioners consider contract length and licence costs, given the planned review.
    [source: NICE HTE3 PDF; HTG660 recommendations]
  • Example language (illustrative): "This programme is offered on the NHS while more evidence is gathered. I'll check in with you every week, and if it isn't helping, we'll change the plan."
  • Watch for: Products used without assessment or without check-ins ("app-only" referral). Unclear ownership of risk between school, voluntary sector and CYPMHS. A product with no current DTAC approval. Working means there is a named supporting practitioner, a weekly contact log, and outcome measures at start and end.

A2. Lumi Nova (BfB Labs), ages 7–12, anxiety

  • Purpose: Exposure-based CBT delivered through an intergalactic role-playing game on a smartphone or tablet. It is for children with mild to moderate anxiety, including social anxiety, separation anxiety and specific fears. [source: Lockwood et al., 2022; NICE HTG660]
  • Steps (as described in the 2022 evaluation):
    1. A professional sets up the child's profile through the VitaMind Hub, and the guardian receives a game key by SMS.
    2. With guardian help, the child chooses up to 3 goals from 14 preset options and works on one goal at a time.
    3. The child builds a graded ladder of exposure steps ("challenges") and completes them in order. Some take place in the game; others are done in real life with guardian support.
    4. Before, during and after each challenge, the game prompts the child to reflect: predicting what will happen and rating their worry.
    5. Psychoeducation about anxiety and exposure is woven into the story. Rewards, avatar customisation and unlockable levels keep the child motivated.
    6. Automated SMS messages, triggered by the child's progress, prompt the guardian to stay involved.
    7. Professionals see goals, worry ratings before and after challenges, the child's rating of goal progress, and the guardian-rated SCAS-P-8 in the Hub.
    8. Play data syncs when the device connects to Wi-Fi.
    9. Daily play was limited to 40 minutes after the first session (which includes a tutorial), in response to parents' screen-time concerns. The current supplier listing confirms limited play time per day without giving the figure.
    [source: Lockwood et al., 2022; G-Cloud listing]
  • Regulatory and data points (as the supplier states them):
    • DTAC approved by NHS England.
    • CE-marked medical device registered with the MHRA. The device class is not stated.
    • Complies with DCB0129 (the NHS clinical risk management standard) and has a Data Security and Protection Toolkit submission.
    • UK GDPR compliant and registered with the ICO.
    • Data is hosted in the UK and encrypted at rest and in transit.
    • At contract end, the buyer chooses whether to receive the data, which is then anonymised.
    • Safeguarding or risk-escalation features of the app are not described in the listing.
    [source: G-Cloud listing]
  • Example language (illustrative): To the child: "In this game you're a treasure hunter, and some of the missions are brave steps you'll try in real life, with your grown-up helping." To the parent: "Your job is to help choose the goal, be there for the real-world challenges, and praise the trying, not just the result."
  • Watch for:
    • In the dashboard: worry ratings that do not fall across repeated steps; goals selected but no out-of-game challenges done; long gaps in play. (Offline play may be under-recorded until the device syncs.)
    • At home: the guardian not engaged.
    • Working looks like the child moving up the ladder, worry ratings falling within and across challenges, and the child and parent rating goal progress.
    • The 2022 study found no rise in depressive symptoms and no adverse events, but it was small and uncontrolled.
    [source: Lockwood et al., 2022]

A3. OSI (Online Support and Intervention for child anxiety), ages 5–12 per NICE, parent-led

  • Purpose: A therapist-supported, parent-led online CBT programme in which parents learn strategies and apply them with their child. It is based on an existing face-to-face parent-led approach that uses an accompanying book (title [uncertain: not verified]). NICE describes three parts: a parent website, a clinical case-management website, and an optional child game app. [source: Hill et al., 2022; NICE HTG660]
  • Steps (as described in the 2022 case series):
    1. The parent receives eight modules, released weekly, each taking about 30 minutes. They mix short text, videos, animations, interactive questions, worksheets and an optional quiz.
    2. At the start of each module, the parent completes routine outcome measures and gets immediate feedback on the platform.
    3. Named content includes a welcome module (Module 0), goal-setting (Module 1), "Facing fears" (Module 3), "Problem-solving" (Module 5) and "Keeping things going" (Module 6). The other module topics are [uncertain: not verified].
    4. After each module, the therapist has a telephone session of about 20 minutes with the parent to review between-session tasks and troubleshoot. A written summary is posted to the platform.
    5. An optional child app, "Monster's Journey: Facing Fears", is introduced in Module 3 to motivate the child to test fears. The parent can award virtual coins through a parent portal.
    6. In the case series, families needed internet access and to read English. Children with autism, significant learning disability or substantial risk or safeguarding concerns were excluded.
    [source: Hill et al., 2022]
  • Example language (illustrative): "In this programme you're the one who takes the steps with your child, and I'm your coach. Each week we'll look at what you tried, what happened, and what to try next."
  • Watch for:
    • Parent outcome scores at the start of each module; whether between-session tasks were attempted; whether the parent is doing "facing fears" steps or avoiding them.
    • Parental distress or anxiety that makes coaching hard.
    • In the case series, gains were largely kept at 4-week follow-up, and most completers were discharged without further anxiety treatment. All measures were parent-reported, and there was no control group.
    [source: Hill et al., 2022; synthesis]

A4. OSCA (Online Social anxiety Cognitive therapy for Adolescents), ages 14–18, social anxiety

  • Purpose: An internet adaptation of cognitive therapy for social anxiety disorder (CT-SAD), based on Clark and Wells' cognitive model. It runs on the same platform as the adult internet version, adapted for adolescents. Use it when social anxiety is the main problem. [source: Leigh & Clark, 2023; NICE HTG660]
  • Steps (as described in the 2023 trial):
    1. The adolescent completes eight core modules in the first 2 weeks. Their content is listed only in the trial's supplement, [uncertain: not verified].
    2. The therapist then releases up to 16 optional modules, chosen for the young person's particular fears and problems (trial average about 7).
    3. Two procedures run over secure, recordable video calls:
      • an experiment comparing self-focused attention and safety behaviours with external focus and dropping them
      • video feedback to update the negative self-image
    4. The adolescent carries out behavioural experiments in daily life, dropping safety behaviours to test social predictions (trial average about 25).
    5. A weekly 20-minute phone call is scheduled. Secure in-programme messages and SMS give encouragement, task reminders and call summaries.
    6. Treatment lasts 14 weeks.
    7. In the trial, total direct therapist contact averaged about 6.6 hours. A clinical psychologist delivered it, with fortnightly specialist supervision.
    8. Trial exclusions:
      • autism or learning disability
      • psychosis
      • substance dependence
      • prior CBT for social anxiety
      • suicidal intent or recurrent self-harm
      • active safeguarding concerns
    [source: Leigh & Clark, 2023]
  • Example language (illustrative): "Let's test the prediction rather than argue with it. What do you think people will notice if you don't rehearse your sentence first? How would we find out?"
  • Watch for:
    • Experiments done while quietly keeping safety behaviours (which blocks belief change).
    • Distress during video feedback.
    • Low log-in time.
    • Working looks like falling belief ratings in feared social predictions and fewer safety behaviours by mid-treatment. In the trial, these changes were the strongest mediators of outcome.
    • Delivery in the trial was by a highly specialist therapist. Local practitioners need training and supervision in CT-SAD procedures (an [uncertain] inference about generalisability).
    [source: Leigh & Clark, 2023; synthesis]

A5. SilverCloud: Space from anxiety, Space from low mood, and Space from low mood and anxiety for teens, ages 15–18

  • Purpose: Internet-based programmes with 7 core modules built on CBT principles, for adolescent anxiety, low mood, or both. [source: NICE HTG660] They are also listed for ages 15 to 18 by an NHS Scotland service, and from age 15 by an English voluntary-sector service. [source: Access Therapies Fife; Big Life Group]
  • Steps (as one NHS-funded service describes delivery):
    1. Referral comes from a professional.
    2. A coordinator holds a suitability discussion and assessment.
    3. The young person works through the programme over about 4 to 8 weeks.
    4. Weekly contact (face to face or by phone) is combined with written or phone reviews. The coordinator monitors progress, gives feedback and encouragement, and reviews risk regularly.
    5. After the supported course, the young person can keep self-help access for up to 12 months.
    6. That service's exclusions:
      • immediate risk, including active self-harm
      • symptoms suggesting psychosis or PTSD
      • wanting to talk through a bereavement
      • currently in another therapy
      • not reading English (the programme is English-only)
    7. The same service offers separate unsupported parent programmes: Supporting an Anxious Child (4–11) and Supporting an Anxious Teen (12+).
    [source: Big Life Group] The 7 module titles, and whether the teen programmes are now branded under SilverCloud's owner, are [uncertain: not verified].
  • Example language (illustrative): "Each week you'll do a section and try the practice tasks. I'll read what you've written, send you a review and check how your mood and worries are going."
  • Watch for:
    • Young people who log in but skip the practice tasks.
    • Mood scores that worsen.
    • Disclosures in journal or free-text entries (decide in advance who reads these and how fast).
    • Working looks like the tasks being completed, the young person using the skills outside the programme, and symptom scores falling.
    [source: Big Life Group; synthesis]

B1. Suitability assessment and product matching

  • Purpose: Meets NICE's requirement for an initial clinical assessment and puts each young person on the right product, or none. [source: NICE HTG660]
  • Steps:
    1. Confirm age and main problem against the product's band (see section 2).
    2. Rate severity with your service's standard measures. NICE prioritises RCADS (parent report for children, self-report for young people); CAIS and SDQ for impairment. Mild to moderate presentations only.
    3. Screen for exclusions used in the studies and services: active self-harm or suicidal intent, psychosis, PTSD symptoms, substance dependence, active safeguarding concerns. [source: Leigh & Clark, 2023; Big Life Group]
    4. Check access: their own device, reliable internet, a private space, digital confidence and reading level or language. NICE notes children lacking these are unlikely to benefit. [source: NICE HTE3 PDF]
    5. For 5 to 12 year olds, check the parent's capacity to lead (OSI) or support (Lumi Nova): time, literacy, their own mental health. [source: Hill et al., 2022; synthesis]
    6. Ask about neurodivergence and adapt the plan (more structure, visual supports, closer review). [synthesis]
    7. Offer choice: digital now, waiting for face-to-face CBT, or both in sequence. [source: NICE HTG660]
  • Example language (illustrative): "There are a few options. One is an online programme with weekly check-ins with me; another is to wait for face-to-face sessions. You can also try the online one and still go on the list. What fits for you?"
  • Watch for: A young person agreeing only to please an adult. Hidden low mood or self-harm behind a presentation that looks like anxiety only. A household without a private space. The assessment is working when the young person can say in their own words what the programme involves and why they chose it. [synthesis]

B2. Consent, assent and the information-sharing agreement

  • Purpose: Gets valid agreement from the young person and, where needed, the parent or carer, and agrees who sees what. The NICE pages do not set out a consent procedure. This section is [synthesis] based on standard UK child mental health practice; follow your organisation's policy.
  • Steps:
    1. Explain the programme, the early-evidence status, the time commitment and the alternatives.
    2. For children under about 12, get parental consent and the child's assent in child-friendly words.
    3. For adolescents, assess the young person's own capacity to consent (in England and Wales, Gillick competence for under-16s; 16 and 17 year olds are presumed to have capacity). Agree how a parent will be involved, respecting the young person's wishes where safe.
    4. Explain the limits of confidentiality. Risk or safeguarding concerns will be shared as policy requires.
    5. Explain what data the product collects, where it is stored, and who sees it (for example, the professional dashboard for Lumi Nova). Point the family to the product's privacy notice. [source: G-Cloud listing; synthesis]
    6. Record consent and assent, and revisit them if circumstances change.
  • Example language (illustrative): To a 9 year old: "This is a game that helps with worries. Your mum or dad will help, and I'll be able to see how your missions are going. Is it OK to try it?" To a 16 year old: "What you write in the programme stays between you and the team, unless I'm worried about your safety. Then I'd talk to you first about who needs to know."
  • Watch for: A parent pressing the child to agree. A young person who does not want parents to know. Disagreement between separated parents with parental responsibility. Re-check assent if the child is resisting play. [synthesis]

B3. Psychoeducation and rationale

  • Purpose: Helps the family understand why the programme works the way it does, so they persist with the uncomfortable parts (exposure, dropping safety behaviours). Each product's own rationale is in A2 to A5; this is how the practitioner reinforces it.
  • Steps:
    1. Ask what the young person and parent already think keeps the anxiety or low mood going.
    2. Link that to the programme's model:
      • Lumi Nova and OSI: avoidance keeps fears going, and step-by-step facing builds confidence. [source: Lockwood et al., 2022; Hill et al., 2022]
      • OSCA: self-focus and safety behaviours keep social fears going. [source: Leigh & Clark, 2023]
      • SilverCloud teens: the links between thoughts, feelings, body and behaviour. [source: Big Life Group]
    3. Expect discomfort. Explain that worry often rises at the start of a step before it falls.
    4. Check understanding by asking them to explain it back.
  • Example language (illustrative): "Avoiding the thing that scares you makes sense in the moment, but it stops your brain learning that you can cope. The programme helps you take small steps so your brain gets new information."
  • Watch for: Parents who think the goal is never to feel anxious. Young people who hear the model as "it's my fault". It is working when they use the model's words to explain a setback. [synthesis]

B4. Onboarding and setting the parent or carer role

  • Purpose: Gets the account working and agrees who does what, scaled to age. This affects engagement directly: in the Lumi Nova study, many families who enrolled never had complete data, and guardian involvement was prompted by SMS. [source: Lockwood et al., 2022]
  • Steps:
    1. Set up the account in the session if possible. For Lumi Nova, create the profile and confirm the guardian has the game key. For OSI, the parent's login. For OSCA and SilverCloud, the young person's login.
    2. Agree a routine: when, where and on which device.
    3. Define the parent's role:
      • OSI: the parent leads and does the modules. [source: Hill et al., 2022]
      • Lumi Nova: the parent helps choose goals and supervises the real-world challenges. [source: Lockwood et al., 2022]
      • Adolescent products: the parent offers practical support and encouragement, as agreed with the young person. [synthesis]
    4. Agree the check-in day, time and channel, and what happens if a check-in is missed.
    5. Give crisis contacts (see B11).
  • Example language (illustrative): "Let's log in together now so we know it works. When in the week will you do it? And Dad, for the real-life missions, your job is to be nearby and calm, not to do it for her."
  • Watch for: Technical failures (no Wi-Fi sync, no SMS received). Shared devices that undermine privacy. Parents taking over adolescent programmes. If the first week shows no log-in, re-contact within days, not at the next scheduled review. [synthesis]

B5. The weekly guided-support check-in

  • Purpose: This is the core of the practitioner's role. NICE requires regular support and weekly check-ins. [source: NICE HTE3 PDF] The product papers describe calls of about 20 minutes. [source: Hill et al., 2022; Leigh & Clark, 2023]
  • Steps (a suggested structure [synthesis] consistent with the product papers):
    1. Open with a brief risk and wellbeing check.
    2. Review the data: module completion, ratings, dashboard or outcome measures.
    3. Review between-session tasks. What was tried? What happened, compared with the prediction?
    4. Problem-solve barriers.
    5. Agree the next step or next module and a specific task.
    6. Summarise in writing. OSI posts a written summary to the platform; OSCA sends summaries by message. [source: Hill et al., 2022; Leigh & Clark, 2023]
    7. Record the contact.
  • Example language (illustrative): "Before we look at the programme, how have things been this week, including any times you felt really low or unsafe? ... You predicted everyone would stare. What actually happened?"
  • Watch for:
    • Check-ins that drift into general counselling and replace the programme.
    • Praising log-ins rather than practice.
    • Missed calls.
    • It is working when tasks are attempted, predictions are tested, and measures move in the right direction over 2 to 4 weeks. [synthesis]

B6. Using outcome and dashboard data

  • Purpose: Tracks progress and spots deterioration early. NICE's evidence plan prioritises symptom, impairment, quality-of-life, engagement and drop-out data. [source: NICE HTE3 PDF]
  • Steps:
    1. Collect baseline measures: RCADS, plus CAIS or SDQ as your service uses them.
    2. Review the product's in-built data at each check-in:
      • Lumi Nova Hub: goals, before and after worry ratings, goal progress, SCAS-P-8. [source: Lockwood et al., 2022]
      • OSI: parent measures at the start of each module. [source: Hill et al., 2022]
      • OSCA: weekly measures. [source: Leigh & Clark, 2023]
    3. Share results with the family in plain language.
    4. Repeat measures at the end.
    5. Record reasons for stopping if the family drops out (a NICE-prioritised gap).
  • Example language (illustrative): "Your worry ratings for the last three missions went from high to medium. That's your brain learning. Let's pick the next step."
  • Watch for: Dashboards that under-record offline use. Scores that rise or flat-line for several weeks. Engagement without improvement. Never rely on the dashboard alone for risk; ask directly. [source: Lockwood et al., 2022; synthesis]

B7. Supporting exposure and behavioural experiments between sessions

  • Purpose: Helps young people and parents carry out the real-world steps that the products prescribe: Lumi Nova out-of-game challenges, OSI "facing fears", OSCA behavioural experiments. [source: product papers]
  • Safety and consent:
    • Steps are chosen with, not imposed on, the child.
    • The child can stop a step.
    • Exposure targets must be safe in themselves (no real danger).
    • Pause and reassess if trauma memories, panic with unexplained physical symptoms, or self-harm urges appear.
    • Exposure is not suitable for unaddressed real threats such as bullying, abuse or unsafe situations; these need safeguarding action, not exposure.
    [synthesis]
  • Steps:
    1. Pick the next step from the programme's ladder or module.
    2. Ask for a specific prediction and a worry rating.
    3. Plan when, where and with whom.
    4. Identify safety behaviours to drop (OSCA) or parent reassurance to reduce, where the programme teaches this.
    5. Debrief the outcome against the prediction.
    6. Decide whether to repeat the step or move up.
  • Example language (illustrative): "On a scale of 0 to 10, how worried do you think you'll be ordering at the counter? What's the worst you expect? Let's see if that happens."
  • Watch for: Steps that are too big (refusal, meltdown) or too small (no anxiety, no learning). Hidden avoidance, such as doing the step but looking at the phone. Parents rescuing early. It is working when predictions are disconfirmed and worry ratings drop across repeats. [source: Lockwood et al., 2022; Leigh & Clark, 2023; synthesis]

B8. Coaching the parent (especially for OSI and Lumi Nova)

  • Purpose: In OSI the therapist coaches the parent, not the child. In Lumi Nova the guardian supports challenges. [source: Hill et al., 2022; Lockwood et al., 2022]
  • Steps:
    1. Review what the parent tried from the module.
    2. Praise specific attempts.
    3. Troubleshoot what got in the way.
    4. Rehearse the next conversation with the child.
    5. Check the parent's own stress, and signpost them to their own support if their anxiety or low mood is high.
    [synthesis, consistent with the OSI call purpose of reviewing tasks and troubleshooting]
  • Example language (illustrative): "You said you stepped back and let him ask the shop assistant himself. What did you notice? What would make the next step easier for both of you?"
  • Watch for: A parent who is overwhelmed, critical or doing everything for the child. Disagreement between carers. Safeguarding concerns that come up during coaching. It is working when the parent independently plans steps and the child's goals progress. [synthesis]

B9. Screen time and engagement conversations

  • Purpose: Addresses parents' screen-time worries and keeps use purposeful. Lumi Nova caps daily play for this reason. [source: Lockwood et al., 2022; G-Cloud listing]
  • Steps:
    1. Ask about the family's existing screen rules.
    2. Explain how the programme limits use, if it does.
    3. Agree a fixed slot that doesn't clash with sleep or homework.
    4. Separate programme time from other gaming.
    5. Review engagement data at check-ins.
    [synthesis]
  • Example language (illustrative): "The game limits how long she can play each day, and the real work is the brave steps off-screen. Shall we pick a regular time, say after tea on school days?"
  • Watch for: Conflict over devices. Late-night use. Engagement that is all in-game with no real-world steps. Disengagement after the novelty wears off, usually in week 2 or 3. [synthesis]

B10. Data privacy and security for minors

  • Purpose: Gives families accurate information about data and meets the organisation's information-governance duties.
  • Steps:
    1. Before first use, confirm with your information governance lead that DTAC approval and a data protection impact assessment are in place.
    2. Tell families what is collected (for example, Lumi Nova's goals, ratings and play data), where it is stored (Lumi Nova: UK-hosted, encrypted), who can see it, and how to make a data request (to the supplier's data protection officer). [source: G-Cloud listing]
    3. For other products, use the supplier's privacy notice, [uncertain: not verified].
    4. Advise on device privacy: own login, screen lock, not sharing accounts.
    5. Check against your service's policy on children's data. The UK ICO's Age Appropriate Design Code applies to online services likely to be used by children, [uncertain: not verified as applied to these products].
    [synthesis]
  • Example language (illustrative): "The programme stores your answers securely in the UK. I can see your progress and ratings so I can support you. Nobody at school sees it unless you agree, or unless there's a safety worry."
  • Watch for: Siblings or partners using the same device. Young people writing sensitive disclosures into free-text fields without knowing who reads them and when. Concern about school staff seeing the data, in school-based delivery. [synthesis]

B11. Risk monitoring, safeguarding and stepping up

  • Purpose: NICE requires safeguarding and risk-management processes so that worsening symptoms are spotted quickly. [source: NICE HTG660] Studies and services excluded people with active self-harm, suicidal intent or active safeguarding concerns. [source: Leigh & Clark, 2023; Hill et al., 2022; Big Life Group]
  • Steps:
    1. At assessment, record risk, protective factors and the escalation route: who to contact in your service, the CYPMHS duty line, the safeguarding lead.
    2. Ask about self-harm and suicidal thoughts directly at every check-in for adolescents, and as appropriate for age with children and parents.
    3. Decide in advance who reviews free-text entries and in-programme messages, and how fast. Tell the young person that messages are not monitored in real time. [synthesis]
    4. Step up when any of these occur:
      • new or rising risk
      • a safeguarding disclosure
      • symptoms beyond mild to moderate
      • a new picture (for example, possible eating disorder, psychosis, trauma)
      • no meaningful change after a reasonable trial, or repeated non-engagement
    5. Stepping up means pausing or ending the digital course and referring to face-to-face CBT or CYPMHS, with a warm handover. [source: NICE HTG660; synthesis]
    6. Follow local safeguarding procedures for any disclosure of harm.
    7. Report device-related adverse events through the MHRA Yellow Card scheme. [source: NICE HTE3 PDF]
  • Example language (illustrative): "Some young people doing this programme have times when they think about hurting themselves or feel it isn't worth going on. Has anything like that happened for you this week?" Then: "Thank you for telling me. This programme isn't enough on its own right now; let's get you more support today."
  • Watch for: Rising RCADS depression scores. Withdrawal from school. Disclosures that come up in the context of exposure work (bullying, abuse). It is working when risk is asked about and recorded at every contact and step-up happens within days, not at the end of the course. [synthesis]

B12. Crisis and safety planning

  • Purpose: None of these products is a crisis service. The young person and parent need a clear plan for out-of-hours distress. [synthesis]
  • Steps:
    1. Agree a brief written plan covering:
      • warning signs
      • things the young person can do themselves
      • trusted adults
      • service contacts in hours
      • out-of-hours contacts (NHS 111 mental health option where available, local crisis line, emergency services)
      • for a parent: safe storage of medicines and sharp objects at home, if risk is present
    2. Give the plan to the young person and, as agreed, to the parent.
    3. Review it if risk changes.
    [synthesis; check local numbers]
  • Example language (illustrative): "If things feel really bad at night when I'm not around, what's your plan? Let's write down who you'd tell and which number you'd call."
  • Watch for: Plans that rely only on the app. A parent who isn't told when the young person agreed they should be. Plans that are out of date. [synthesis]

B13. Ending, relapse prevention and transition

  • Purpose: Consolidates gains and plans next steps. OSI includes a "Keeping things going" module, and one SilverCloud service keeps self-help access for 12 months after the course. [source: Hill et al., 2022; Big Life Group]
  • Steps:
    1. Review the start and end measures and the goals.
    2. Name the skills that helped.
    3. Identify early warning signs and the next steps the young person can take alone.
    4. Agree when and how to re-refer.
    5. Close the account or keep self-help access as the product allows.
    6. If symptoms persist, refer on (face-to-face CBT or CYPMHS) with a summary of what was tried.
    [source: NICE HTG660; synthesis]
  • Example language (illustrative): "Look at where you started on the scale and where you are now. Which steps made the biggest difference? What will you do if the worries start creeping back?"
  • Watch for: Abrupt drop-off without an ending. Families who feel they "failed" the app; reframe this as useful information for choosing next care. [synthesis]

B14. Integrating with other therapy and collaborative care

  • Purpose: Fits digital CBT into a wider plan. NICE says the young person can have face-to-face CBT afterwards, and that use elsewhere in the pathway depends on individual clinical assessment. One service excludes young people in concurrent therapy. [source: NICE HTG660; Big Life Group]
  • Steps:
    1. Check whether other therapy or school support is already in place.
    2. Avoid running parallel, conflicting CBT.
    3. If the young person is waiting for face-to-face therapy, agree what will be handed over from the digital course.
    4. Liaise with the school or GP with consent.
    5. If medication is being considered by a prescriber, route all questions to the prescriber. Do not advise on it.
    [synthesis]
  • Example language (illustrative): "When you start with the CBT therapist, it'll help to share your programme summary so they can build on what you've already done."
  • Watch for: Duplicate or conflicting homework. Unclear clinical responsibility between school, voluntary sector and CYPMHS teams. [synthesis]

B15. Service-level governance and evidence generation

  • Purpose: NICE asks providers to have structures to review, authorise and monitor new devices, and to collect evidence on prioritised outcomes. [source: NICE HTE3 PDF; HTG660 recommendations]
  • Steps:
    1. Keep a log of engagement, outcomes (RCADS, CAIS or SDQ, CHU-9D as feasible), drop-outs and reasons, and adverse events.
    2. Feed these data back through the service.
    3. Check DTAC status and contract terms at renewal.
    4. Recheck NICE status, since the guidance is due for review.
    [source: NICE HTE3 PDF; synthesis]
  • Example language (illustrative, to a manager): "We're using this under an early value assessment, so we need to record outcomes and drop-out reasons, and recheck the NICE position before the contract renews."
  • Watch for: No data collected. Contract lengths that run past the review date. Products used outside their age band. [synthesis]

5. Handling problems

NICE and the product papers say little about troubleshooting. The guidance below is [synthesis] unless a source is tagged.

  • Non-engagement (no log-in, or stops after week 1 or 2).
    • Re-contact quickly.
    • Ask what got in the way: technology, time, privacy, or the content feeling boring, too hard or too childish.
    • Fix practical barriers, such as setting up together or agreeing a fixed slot.
    • If there is still no engagement after two attempts, offer the alternative pathway (face-to-face CBT) rather than repeating the offer.
    • Record the reasons for stopping, which NICE prioritises. [source: NICE HTE3 PDF; synthesis]
    • Example (illustrative): "It sounds like the programme hasn't fitted your week. That's useful to know. Do you want to try it differently, or would another kind of help suit you better?"
  • Engaged but not improving.
    • Check whether real-world steps are being done, or only in-app content. Lumi Nova data showed many children selecting goals but fewer completing out-of-game challenges. [source: Lockwood et al., 2022]
    • Check for hidden safety behaviours (OSCA) and for parent accommodation (OSI). [source: Leigh & Clark, 2023; synthesis]
    • Reconsider whether the problem is really mild to moderate, or whether something else is driving it (low mood, bullying, neurodevelopmental needs). Step up if needed.
  • Avoidance of exposure steps, or refusal.
    • Make the step smaller.
    • Check the child's assent.
    • Rehearse in session.
    • Coach the parent to encourage without forcing.
    • Never use punishment or coercion to get a child through a step.
    • Example (illustrative): "That step was too big. Let's find one halfway between where you are and that."
  • Overwhelm or high distress during a step or during video feedback (OSCA).
    • Stop the step and ground the young person.
    • Debrief what was learned.
    • Resume at a lower step.
    • If distress links to trauma, self-harm urges or panic with unexplained physical symptoms, pause and reassess suitability; arrange a medical review if physical symptoms are unexplained.
  • Parent-related problems (OSI and Lumi Nova): parent too busy, anxious, critical, or over-involved in an adolescent programme.
    • Normalise the difficulty.
    • Reduce to one achievable task.
    • Signpost the parent to their own support.
    • For adolescents, renegotiate the parent's role with the young person.
    • If parental behaviour raises safeguarding concerns, follow procedures.
  • Ruptures with the supporting practitioner (feeling monitored, judged by dashboard data, or "handed an app instead of a person").
    • Name it.
    • Explain why you see the data and how it helps.
    • Offer more human contact within the model.
    • Remind them of the choice to wait for, or add, face-to-face care. [source: NICE HTG660 on choice; synthesis]
    • Example (illustrative): "I wonder if it feels like I'm watching your scores rather than listening to you. Tell me what this has been like."
  • Risk emerges mid-course.
    • Follow B11: assess, safety-plan, step up, and inform the safeguarding lead as policy requires.
    • Do not continue the digital course as the main treatment while risk is high.
  • Technical, access and privacy problems (no Wi-Fi sync, shared device, no private room).
    • NICE notes children without adequate equipment, internet or privacy are unlikely to benefit. [source: NICE HTE3 PDF]
    • Offer a different setting (for example, a private room at school) or face-to-face care.
  • Neurodivergent young people.
    • The evidence largely excluded them. [source: NICE HTE3 PDF; Hill et al., 2022; Leigh & Clark, 2023]
    • Add structure and visual supports, check that the content's language and pace fit, review weekly, and lower the threshold for stepping up.
  • Language and literacy barriers.
    • SilverCloud is English-only in at least one service, and OSI required reading English in its study. [source: Big Life Group; Hill et al., 2022]
    • Offer interpreted face-to-face care rather than asking a child to interpret for a parent.
  • Questions about evidence ("Does this really work?").
    • Answer honestly. NICE found the evidence base very limited for all five technologies, mostly single-arm studies with small samples and one randomised trial. Early cost modelling was promising but uncertain. [source: NICE HTE3 PDF]
    • The single randomised trial (OSCA versus waitlist) showed large effects but was small, used a waitlist control and had one specialist therapist. [source: Leigh & Clark, 2023]
    • The Lumi Nova and OSI studies were uncontrolled. [source: Lockwood et al., 2022; Hill et al., 2022]
    • Example (illustrative): "NICE allows this while more evidence is gathered. Early results are encouraging but limited, so we'll check your progress closely and change course if it isn't helping."
  • The product's status changes (DTAC lapse, contract ending, NICE review, supplier change).
    • Plan a managed ending, export or close the data according to the contract, and offer an alternative. [source: G-Cloud listing on data at contract end; synthesis]

Sources

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