Technology-Enhanced Behavioral Parent Training: The Relationship Between Technology Use and Efficiency of Service Delivery.

Behavior disorders (BDs) are common and, without treatment, can have long-term impacts on child and family health. Behavioral Parent Training (BPT) is the standard of care intervention for early-onset BDs; however, structural socioeconomic barriers hinder treatment outcomes for low-income families. While digital technologies have been proposed as a mechanism to improve engagement in BPT, research exploring the relationship between technology use and outcomes is lacking. Thus, this study with 34 low-income families examined the impact of parents' use of adjunctive mobile app components on treatment efficiency in one technology-enhanced (TE-) BPT program, Helping the Noncompliant Child (HNC). While parent use of the TE-HNC app and its impact on the efficiency of service delivery varied across specific components, increased app use significantly reduced the number of weeks required for families to achieve skill mastery. Implications for the design and development of behavior intervention technologies in general, as well as for BPT in particular, are discussed.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery.

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Differences in mental health engagement and follow-up among Black and White patients after traumatic injury.

BACKGROUND: Severe injury necessitating hospitalization is experienced by nearly three million US adults annually. Posttraumatic stress disorder and depression are prevalent clinical outcomes. The mechanisms by which programs equitably promote mental health recovery among trauma-exposed patients are understudied. We evaluated clinical outcomes and engagement among a cohort of Black and White patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate mental health recovery after traumatic injury. METHODS: Trauma Resilience and Recovery Program is a four-step model that includes (1) bedside psychoeducation about mental health recovery following traumatic injury, (2) a text-messaging symptom tracking system, (3) a 30-day postinjury mental health screen, and (4) referrals to mental health services. Data describe 1,550 patients enrolled in TRRP within a Level I trauma center ( Mage = 40.86; SD, 17.32), 611 of whom identified as Black (74.5% male) and 939 of whom identified as White (67.7% male). RESULTS: Enrollment in TRRP was nearly universal (97.9%) regardless of race or injury mechanism. Enrollment and usage of the text-message system were statistically similar between Black (35.7%) and White patients (39.5%). Trauma Resilience and Recovery Program reengaged Black and White patients at a similar rate at the 30-day postinjury follow-up. However, Black patients were more likely to report peritraumatic distress at the bedside and clinical elevations in posttraumatic stress disorder and depression on the 30-day screen. Referrals were more likely to be accepted by Black patients relative to White patients with clinically elevated symptoms. CONCLUSION: Enrollment and engagement were comparable among Black and White patients served by TRRP. Data provide preliminary evidence to suggest that TRRP is feasible and acceptable and engages patients in mental health follow-up equitably. However, research that includes careful measurement of social determinants of health and long-term follow-up examining initiation, completion, and benefit from treatment is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Socioeconomic Indicators Linked to Parent Health-Related Technology Use: Cross-sectional Survey.

BACKGROUND: Despite the prevalence of parent health information seeking on the internet and its impact on parenting behavior, there is a paucity of research on parents of young children (ages 3 to 8 years). Given the importance of this developmental period, exploring how family socioeconomic indicators linked to the digital divide and health inequities affect parent proxy- and self-seeking is critical to further understanding variability in health information seeking and associated outcomes. OBJECTIVE: This study aimed to explore parental health-related technology use (HTU), the process by which parents engage in support, advice, and information-seeking behavior related to their (self-seeking) and their children's (proxy seeking) health across a range of hardware devices (eg, tablet, wearable, smartphone, laptop, and desktop computer) and sources (eg, search engines, mobile applications, social media, and other digital media). METHODS: A cross-sectional study including 313 parents and guardians of children ages 3 to 8 years recruited through Amazon Mechanical Turk (MTurk) was conducted. Parents were asked to complete a self-administered questionnaire on a broad range of parenting and parent-related constructs, including sociodemographic information, technology device ownership, and engagement in and use, features, and perceptions of HTU. Descriptive and bivariate analyses (chi-square tests) were performed to identify patterns and investigate associations between family socioeconomic indicators and parent HTU. RESULTS: The overwhelming majority (301/313, 96%) of parents of young children reported engaging in HTU, of which 99% (300/301) reported using search engines (eg, Google), followed by social media (62%, 188/301), other forms of digital media (eg, podcasts; 145/301, 48%), and mobile applications (114/301, 38%). Parents who engaged in HTU reported seeking information about their child's behavior and discipline practices (260/313, 83%), mental or physical health (181/313, 58%), and academic performance (142/313, 45%). Additionally, nearly half (134/313, 43%) of parents reported searching for advice on managing their stress. Among parents who reported using each source, an overwhelming majority (280/300, 93%) indicated that search engines were a helpful online source for proxy- and self-seeking, followed by social media (89%, 167/188), other digital media (120/145, 83%), and mobile apps (87/114, 76%). Among parents who reported using any technology source, approximately one-fifth reported that technology sources were most comfortable (61/311, 20%), most understanding (69/311, 22%), and most influential toward behavior change (73/312, 23%) compared to traditional sources of health information-seeking, including mental health professionals, other health care professionals, school professionals, community leaders, friends, and family members. Indicators of family socioeconomic status were differentially associated with frequency and perceptions of and search content associated with parent HTU across technology sources. CONCLUSIONS: The findings of this study underscore critical considerations in the design and dissemination of digital resources, programs, and interventions targeting parent and child health, especially for families in traditionally underserved communities.

Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury.

Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.

A randomized controlled trial of technology-enhanced behavioral parent training: sustained parent skill use and child outcomes at follow-up.

BACKGROUND: Early-onset (3-8 years old) disruptive behavior disorders (DBDs) have been linked to a range of psychosocial sequelae in adolescence and beyond, including delinquency, depression, and substance use. Given that low-income families are overrepresented in statistics on early-onset DBDs, prevention and early-intervention targeting this population is a public health imperative. The efficacy of Behavioral Parent Training (BPT) programs such as Helping the Noncompliant Child (HNC) has been called robust; however, given the additional societal and structural barriers faced by low-income families, family engagement and retention barriers can cause effects to wane with time. This study extends preliminary work by examining the potential for a Technology-Enhanced HNC (TE-HNC) program to improve and sustain parent skill proficiency and child outcomes among low-income families. METHODS: A randomized controlled trial with two parallel arms was the design for this study. A total of 101 children (3-8-years-old) with clinically significant problem behaviors from low-income households were randomized to HNC (n = 54) or TE-HNC (n = 47). Participants were assessed at pre-treatment, post-treatment, 3-month, and 6-month follow-ups. Primary outcomes were parent-reported and observed child behavior problems. Secondary outcomes included observed parenting skills use (ClinicalTrials.gov Identifier: NCT02191956). RESULTS: Primary analyses used latent curve modeling to examine treatment differences in the trajectory of change during treatment, maintenance of treatment gains, and levels of outcomes at the 6-month follow-up. Both programs yielded improvements in parenting skills and child problems at post-treatment. However, TE-HNC families evidenced greater maintenance of parent-reported and observed child behavior and observed positive parenting skills at the 6-month follow-up. CONCLUSIONS: Our findings contribute to an ongoing line of work suggesting that technology-enhanced treatment models hold promise for increasing markers of engagement in BPT and sustaining long-term outcomes among low-income families.

Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study.

BACKGROUND: Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context. OBJECTIVE: The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching. METHODS: In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated. RESULTS: Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (ß=-1.2; P<.001), generalized anxiety (ß=-1.1; P<.001), and social anxiety (ß=-2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=-2.1; P=.03). CONCLUSIONS: This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program.

Optimizing Engagement in Behavioral Parent Training: Progress Toward a Technology-Enhanced Treatment Model.

Low-income families are more likely to have a child with an early-onset Behavior Disorder (BD); yet, socioeconomic strain challenges engagement in Behavioral Parent Training (BPT). This study follows a promising pilot to further examine the potential to cost-effectively improve low-income families' engagement in and the efficiency of BPT. Low-income families were randomized to (a) Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003), a weekly, mastery-based BPT program that includes both the parent and child or (b) Technology-Enhanced HNC (TE-HNC), which includes all of the standard HNC components plus a parent mobile application and therapist web portal that provide between-session monitoring, modeling, and coaching of parent skill use with the goal of improved engagement in the context of financial strain. Relative to HNC, TE-HNC families had greater homework compliance and mid-week call participation. TE-HNC completers also required fewer weeks to achieve skill mastery and, in turn, to complete treatment than those in HNC without compromising parent satisfaction with treatment; yet, session attendance and completion were not different between groups. Future directions and clinical implications are discussed.

Patient Engagement in a Technology-Enhanced, Stepped-Care Intervention to Address the Mental Health Needs of Trauma Center Patients.

BACKGROUND: Annually, post-traumatic stress disorder, depression, or both, develop in the first year after injury in more than 400,000 adults treated in US trauma centers (≥20%). Yet, few trauma centers monitor and address mental health recovery, and there is limited evaluation and high structural variability across existing programs. More research is needed to guide efforts to establish such programs and to inform national standards and recommendations. STUDY DESIGN: This article describes patient engagement in a stepped-care service to address patients' mental health needs. Trauma-activation patients admitted to our Level I trauma center for at least 24 hours were approached before discharge. Patients were provided education in person at the bedside (step 1), symptom monitoring via a 30-day text-messaging tool (step 2), telephone screening approximately 30 days post injury (step 3), and, when appropriate, mental health treatment referrals and treatment (step 4). RESULTS: We approached and educated 1,122 patients (56%) on the floor during a 33-month period. Of these, 1,096 patients (98%) enrolled in our program and agreed to 30-day follow-up mental health screening. We reached 676 patients for the 30-day screen, 243 (36%) of these patients screened positive for post-traumatic stress disorder and/or depression. Most of the 243 patients who graduated to step 4 accepted treatment referrals (68%) or were already receiving services from a provider (7%). Home-based telemental health was preferred by 66% of patients who accepted referrals. CONCLUSIONS: This work demonstrates the feasibility of an evidence-based, technology-enhanced, stepped-care intervention to address the mental health needs of trauma center patients. Strategies to reach a higher percentage of patients in follow-up are needed. We recommend trauma centers test and adopt broad-based approaches to ensure optimal long-term patient outcomes.

Hybrid type 1 randomized controlled trial of a tablet-based application to improve quality of care in child mental health treatment.

The quality of child mental health care is highly variable in community practice settings. Innovative technology-based solutions may be leveraged to improve quality of care and, in turn, treatment outcomes. This is a protocol paper that describes an innovative study design in which we rigorously evaluate the effectiveness of a tablet-assisted intervention, Supporting Providers and Reaching Kids (SPARK). SPARK consists of a collection of interactive games and activities that are designed to improve provider fidelity and child engagement in evidence-based psychotherapies. The methodology also allows us to explore the implementation and sustainability of a technology-enhanced intervention in more than two dozen community practice settings. This paper includes a description and justification for sample selection and recruitment procedures, selection of assessment measures and methods, design of the intervention, and statistical evaluation of critical outcomes. Novel features of the design include the tablet-based toolkit approach that has strong applicability to a range of child mental health interventions and the use of a hybrid type 1 effectiveness-implementation trial that allows for the simultaneous investigation of the effectiveness of the intervention and the implementation context. Challenges related to the implementation of a technology-enhanced intervention in existing mental health clinics are discussed, as well as implications for future research and practice.

BPT for Early-Onset Behavior Disorders: Examining the Link Between Treatment Components and Trajectories of Child Internalizing Symptoms.

Behavioral Parent Training (BPT) is the standard of care for early-onset Behavior Disorders (BDs). Preliminary evidence suggests that BPT may also lead to improvement in comorbid symptomatology, particularly internalizing problems, in children with BDs, yet less is currently known about how BPT produces such cascading effects. To begin to address this gap in the literature, trajectory analyses were used to examine the link between treatment components of one mastery-based BPT program, Helping the Noncompliant Child (HNC), and child internalizing symptoms over the course of treatment. Findings revealed that parental use of the Attends skill (i.e., parental description of child activity with warmth and enthusiasm) over time was significantly associated with decreases in trajectories of child internalizing symptoms across treatment. Further probing of these effects revealed that parent use of average or above-average levels of Attends across treatment sessions led to significant reductions in child internalizing symptoms by Sessions 7 to 10 of treatment. Consistent with the movement toward a modular approach to the treatment of children, findings highlight the importance of identifying particular BPT skills that can be used in treatment to target multiple comorbid child symptom clusters. Clinical implications and future directions are discussed.

Conducting Psychological Intervention Research in the Information Age: Reconsidering the "State of the Field".

Enthusiasm for technology in mental health has evolved as a function of its promise to increase the reach and impact of services, particularly for traditionally at-risk and underserved groups. Preliminary findings suggest that technology-enhanced interventions indeed hold promise for increasing engagement in and outcomes of evidence-based treatment approaches. The time- and resourceintensive nature of traditional randomized control trials, however, may be even more of a challenge for further advancement in this area, given the rapid innovation of consumer driven new product development. Accordingly, this review aims to summarize how a broader range of scientific designs and analyses may be necessary in order to further advance and optimize the reach and impact of technology-enhanced psychological practice. Examples of various approaches are provided and recommendations are provided for future work in this area.

Trauma Resilience and Recovery Program: Addressing Mental Health in Pediatric Trauma Centers.

OBJECTIVE: Approximately 225,000 children sustain injuries requiring hospitalization annually. Posttraumatic stress disorder (PTSD) and depression are prevalent among pediatric patients and caregivers post-injury. Most U.S. trauma centers do not address patients' mental health needs. Better models of care are needed to address emotional recovery. This article describes the engagement and recovery trajectories of pediatric patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate emotional recovery following hospitalization. METHODS: TRRP is designed to (a) provide in-hospital education about post-injury emotional recovery and assess child and caregiver distress; (b) track mental health symptoms via a 30-day text-messaging program; (c) complete 30-day PTSD and depression phone screens; and (d) provide evidence-based treatment via telehealth or in-person services or referrals, if needed. All 154 families approached were offered TRRP services, 96% of whom agreed to enroll in TRRP. Most patients were boys (59.8%), and average age was 9.12 years [standard deviation (SD) = 5.42]. Most injuries (45.8%) were sustained from motor vehicle accidents. RESULTS: In hospital, 68.5% of caregivers and 78.3% of children reported clinically significant distress levels. Over 60% of families enrolled in the texting service. TRRP re-engaged 40.1% of families for the 30-day screen, 35.5% of whom reported clinically significant PTSD (M = 13.90, SD = 11.42) and/or depression (M = 13.35, SD = 11.16). Most (76%) patients with clinically significant symptomology agreed to treatment. CONCLUSIONS: Our intervention model was feasible and increased reach to families who needed services. Efforts to improve follow-up engagement are discussed, as are initial successes in implementing this model in other pediatric trauma centers.

Parent-therapist alliance and technology use in behavioral parent training: A brief report.

Researchers propose that technology has the capacity to promote therapeutic alliance; however, clinicians worry the opposite is true. Behavioral parent training (BPT), an approach that is reliant on the parent as the mechanism of change, is the standard of care for early-onset (3-8 years old) behavior disorders. Importantly, behavior disorders are among the most common reasons parents seek mental health services for their children; therefore, BPT affords an ideal context within which to better understand the potential interrelationship between technology and therapeutic alliance. To this end, this study examined the link between smartphone-enhancements to 1 BPT program and parent-therapist alliance in 9 families of children with early-onset behavior disorders. Findings suggest relative differences in patterns of alliance and use of the smartphone-enhancements within the technology-enhanced group, patterns that have implications for better understanding the impact of technology on the therapeutic process, the deployment of existing technology-enhanced services, and the development of future technology-enhanced services. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Adoption of Technology-Enhanced Treatments: Conceptual and Practical Considerations.

As the efficacy of technology-enhanced mental health service delivery models (i.e., supportive or adjunctive technological tools) are examined, we must inform and guide clinician decision-making regarding acceptance and, in turn, uptake. Accordingly, this review aims to move beyond traditional discussions of geographic barriers by integrating, reconciling, and extending literatures on dissemination and implementation, as well as technology uptake, in order to anticipate and address organizational and clinician barriers to adoption of technology-enhancements. Specifically, a five-stage model is proposed to address organizational readiness for and clinician acceptance of technology-enhancements to evidence-based treatments, as well as the relevance of current adoption strategies for technology-enhanced services. Our aim is to provide a guiding framework for future research and practice.

Caregiver Use of the Core Components of Technology-Enhanced Helping the Noncompliant Child: A Case Series Analysis of Low-Income Families.

Children from low-income families are more likely to develop early-onset disruptive behavior disorders (DBDs) compared to their higher income counterparts. Low-income families of children with early-onset DBDs, however, are less likely to engage in the standard-of-care treatment, behavioral parent training (BPT), than families from other sociodemographic groups. Preliminary between-group findings suggested technology-enhanced BPT was associated with increased engagement and boosted treatment outcomes for low-income families relative to standard BPT. The current study used a case series design to take this research a step further by examining whether there was variability in use of, and reactions to, the smartphone enhancements within technology-enhanced BPT and the extent to which this variability paralleled treatment outcome. Findings provide a window into the uptake and use of technology-enhanced service delivery methods among low-income families, with implications for the broader field of children's mental health.

Socioeconomic status, parenting, and externalizing problems in African American single-mother homes: A person-oriented approach.

African American youth, particularly those from single-mother homes, are overrepresented in statistics on externalizing problems. The family is a central context in which to understand externalizing problems; however, reliance on variable-oriented approaches to the study of parenting, which originate from work with intact, middle-income, European American families, may obscure important information regarding variability in parenting styles among African American single mothers, and in turn, variability in youth outcomes as well. The current study demonstrated that within African American single-mother families: (a) a person-, rather than variable-, oriented approach to measuring parenting style may further elucidate variability; (b) socioeconomic status may provide 1 context within which to understanding variability in parenting style; and (c) 1 marker of socioeconomic status, income, and parenting style may each explain variability in youth externalizing problems; however, the interaction between income and parenting style was not significant. Findings have potential implications for better understanding the specific contexts in which externalizing problems may be most likely to occur within this at-risk and underserved group.