Harnessing innovative technologies to advance children's mental health: Behavioral parent training as an example

Abstract

Disruptive behaviors of childhood are among the most common reasons for referral of children to mental health professionals. Behavioral parent training (BPT) is the most efficacious intervention for these problem behaviors, yet BPT is substantially underutilized beyond university research and clinic settings. With the aim of addressing this research-to-practice gap, this article highlights the considerable, but largely unrealized, potential for technology to overcome the two most pressing challenges hindering the diffusion of BPT: (1). The dearth of BPT training and supervision opportunities for therapists who work with families of children with disruptive behaviors; and (2). The failure to engage and retain families in BPT services when services are available. To this end, this review presents a theoretical framework to guide technological innovations in BPT and highlights examples of how technology is currently being harnessed to overcome these challenges. This review also discusses recommendations for using technology as a delivery vehicle to further advance the field of BPT and the potential implications of technological innovations in BPT for other areas of children's mental health are discussed.

Introduction

The prevalence of mental disorders among youth worldwide is estimated to be 20% (World Health Organization, 2001). In the U.S. alone, one-fifth of children, up to 15 million, have a diagnosable disorder (Burns et al., 1999, Kazak et al., 2010). Disorders of childhood affect a wide range of youth functioning, including family and peer relationships, as well as academic performance and persist into adolescence and adulthood, exacerbating the risks for individual disability and impairment (see Costello et al., 2006, Fleitlich and Goodman, 2001, Graeff-Martins et al., 2008, for reviews). In addition to the psychosocial costs, rates of childhood disorders fail to reflect the far-reaching economic effects for families and society. For example, annual treatment costs for children in the U.S. alone are estimated to be more than $11 billion dollars (Eyberg, Nelson, & Boggs, 2008).

Given the prevalence, wide-ranging consequences, and costs associated with childhood disorders, increasing the availability and utilization of evidence-based interventions is a critical public health concern (Graeff-Martins et al., 2008). Yet, the provision of services for children's mental health has been recognized as at least “problematic” (Kazak et al., 2010, p. 85), with some noting that the failure to more adequately respond to the mental health needs of children and adolescents will result in “disability and suffering, reduce the ability to achieve health goals, and undermine the capacity for countries to be productive in an increasingly competitive world” (Belfer & Saxena, 2006, p. 552). Accordingly, the transfer of evidence-based interventions from the university clinic and research setting to community-based practice has been identified as a public health priority (National Advisory Mental Health Council, 2001). To this end, leaders in mental health have called for a paradigm shift in clinical services and highlight that technology is at the forefront of this shift (Aguilera and Muench, 2012, Kazdin and Blasé, 2011).

Building upon the broader recognition that technology has the potential to change the landscape of mental health service research and delivery, this article highlights the capacity for technology to address the obstacles limiting the reach of one evidence-based treatment in particular, behavioral parent training (BPT) for childhood disruptive behavior disorders (DBDs). There are four primary reasons for our choice to focus on this intervention approach. First, disruptive behaviors (e.g., noncompliance, defiance, aggression) are among the most common reasons children are referred to mental health care (e.g., Egger and Angold, 2006, Lundahl et al., 2006, Zisser and Eyberg, 2010). For example, in their epidemiological review of childhood mental disorders, Marikangas, Nakamura, and Kessler (2009) reported that the 12-month prevalence of DBDs worldwide is second only to anxiety disorders in children and adolescents (followed by mood and substance use disorders). Accordingly, DBDs present challenges for both families and society, challenges that highlight the critical public health impact of increasing the availability of early intervention programs and engaging and retaining families in those programs.

In addition, there are multiple BPT programs for children with DBDs, each rooted in a common theoretical foundation and, in turn, a common treatment approach (e.g., Galbraith et al., 2009, Kelly et al., 2000, McKleroy et al., 2006). The early starter model (similar models include the cascade model or childhood onset type) proposes that parenting behaviors play a key role in propelling a child toward the initiation of disruptive behaviors and the escalation to DBDs, including oppositional defiant disorder and conduct disorder, as well as their correlates (e.g. risk behaviors) (see Dodge et al., 2009, Holden, 2010, McMahon and Forehand, 2003, Moffitt et al., 2008, for reviews). Specifically, coercive processes between the parent and child emerge early in the child's development (see Granic and Patterson, 2006, McMahon and Forehand, 2003, for reviews) and often persist into and through adolescence (Burke, Pardini, & Loeber, 2008). In turn, evidence-based BPT programs target these coercive family processes through a treatment approach that includes both the parent(s) and child and utilizes the following core treatment components: modeling, skill-building, and home practice. Collectively, this core of BPT treatment components are focused on increasing positive attention for appropriate child behavior, removing parental attention for inappropriate child behavior, and implementing more effective instructions and consequences for noncompliance (see Forehand et al., 2010a, Garland et al., 2008, McMahon and Forehand, 2003, Reyno and McGrath, 2006, for reviews). Consideration of this common pool of available BPT programs is critical as it suggests that technology which successfully enhances therapist training in and/or service delivery of one BPT program should function similarly with other BPT programs as well.

Third, BPT for childhood DBDs has substantial research to support its efficacy. As highlighted by Chorpita et al. (2011, pp. 161, 163), “… the vast majority of positive findings continue to support PMT (parent management training), which also demonstrated the largest effect size…” for treatment of disruptive behaviors (note: BPT and PMT are used interchangeably; also see Chorpita et al., 2011, Dretzke et al., 2009, Eyberg et al., 2008, Kaminski et al., 2008, Lundahl et al., 2006, McCart et al., 2006, McMahon et al., 2006, Serketich and Dumas, 1996, Weisz and Gray, 2008, for reviews). Accordingly, the primary obstacles to successful intervention with families of children with DBDs is not a lack of evidence-based early intervention programs, but rather inadequate diffusion of BPT programs to therapists in real-world settings and disappointing rates of engagement and retention of families in services. Accordingly, we believe that the most important message to convey in this review is not the types of technology (i.e., “black box”) that are currently being utilized in BPT, but how technology is used to overcome these two obstacles in particular (i.e., function of technology; Ritterband, Thorndike, Cox, Kovatchev, & Gonder-Frederick, 2009, p. 22).

A final reason for focusing this review on BPT as an example for children's mental health more broadly is that the incorporation of technology, albeit in its most basic forms (i.e., videotape modeling), is firmly rooted in the history of BPT (e.g., Flanagan et al., 1979, Nay, 1976, O'Dell et al., 1982). This review builds upon this history of technology in the field of BPT, as well as prior reviews that have highlighted the increasingly central role of technology in behavior change interventions (see Barak et al., 2008, Boschen and Casey, 2008, Clough and Casey, 2011, Kazdin and Blasé, 2011, Spek et al., 2007, Tate and Zabinski, 2004, Wantland et al., 2004, for reviews). It is important to note here, however, that prior reviews have focused primarily on interventions targeting adults, with far less attention to the role of technology in the treatment of childhood disorders, particularly disorders on the externalizing spectrum (e.g., see Graeff-Martins et al., 2008, Kazdin, 2008, Ybarra and Eaton, 2005, for reviews). As such, this review extends the range of solutions raised in a previous publication (Forehand & Kotchick, 2002) by making specific recommendations for taking fuller advantage of technological innovations that are already available to consumers.