Patricia Lingley-Pottie

Telephone-Based Mental Health Interventions for Child Disruptive Behavior or Anxiety Disorders: Randomized Trials and Overall Analysis

OBJECTIVE Most children with mental health disorders do not receive timely care because of access barriers. These initial trials aimed to determine whether distance interventions provided by nonprofessionals could significantly decrease the proportion of children diagnosed with disruptive behavior or anxiety disorders compared with usual care. METHOD In three practical randomized controlled trials, 243 children (80 with oppositional-defiant, 72 with attention-deficit/hyperactivity, and 91 with anxiety disorders) were stratified by DSM-IV diagnoses and randomized to receive the Strongest Families intervention (treatment) or usual care (control). Assessments were blindly conducted and evaluated at 120, 240, and 365 days after randomization. The intervention consisted of evidence-based participant materials (handbooks and videos) and weekly telephone coach sessions. The main outcome was mental health diagnosis change. RESULTS Intention-to-treat analysis showed that for each diagnosis significant treatment effects were found at 240 and 365 days after randomization. Moreover, in the overall analysis significantly more children were not diagnosed as having disruptive behavior or anxiety disorders in the treatment group than the control group (120 days: χ(2)(1) = 13.05, p < .001, odds ratio 2.58, 95% confidence interval 1.54-4.33; 240 days: χ(2)(1) = 20.46, p < .001, odds ratio 3.44, 95% confidence interval 1.99-5.92; 365 days: χ(2)(1) = 13.94, p < .001, odds ratio 2.75, 95% confidence interval 1.61-4.71). CONCLUSIONS Compared with usual care, telephone-based treatments resulted in significant diagnosis decreases among children with disruptive behavior or anxiety. These interventions hold promise to increase access to mental health services. CLINICAL TRIAL REGISTRATION INFORMATION Strongest Families: Pediatric Disruptive Behaviour Disorder, http://www.clinicaltrials.gov, NCT00267579; Strongest Families: Pediatric Attention-Deficit/Hyperactivity Disorder, http://www.clinicaltrials.gov, NCT00267605; and Strongest Families: Pediatric Anxiety, http://www.clinicaltrials.gov, NCT00267566.

Internet-Assisted Parent Training Intervention for Disruptive Behavior in 4-Year-Old Children: A Randomized Clinical Trial

IMPORTANCE There is a large gap worldwide in the provision of evidence-based early treatment of children with disruptive behavioral problems. OBJECTIVE To determine whether an Internet-assisted intervention using whole-population screening that targets the most symptomatic 4-year-old children is effective at 6 and 12 months after the start of treatment. DESIGN, SETTING, AND PARTICIPANTS This 2-parallel-group randomized clinical trial was performed from October 1, 2011, through November 30, 2013, at a primary health care clinic in Southwest Finland. Data analysis was performed from August 6, 2015, to December 11, 2015. Of a screened population of 4656 children, 730 met the screening criteria indicating a high level of disruptive behavioral problems. A total of 464 parents of 4-year-old children were randomized into the Strongest Families Smart Website (SFSW) intervention group (n = 232) or an education control (EC) group (n = 232). INTERVENTIONS The SFSW intervention, an 11-session Internet-assisted parent training program that included weekly telephone coaching. MAIN OUTCOMES AND MEASURES Child Behavior Checklist version for preschool children (CBCL/1.5-5) externalizing scale (primary outcome), other CBCL/1.5-5 scales and subscores, Parenting Scale, Inventory of Callous-Unemotional Traits, and the 21-item Depression, Anxiety, and Stress Scale. All data were analyzed by intention to treat and per protocol. The assessments were made before randomization and 6 and 12 months after randomization. RESULTS Of the children randomized, 287 (61.9%) were male and 79 (17.1%) lived in other than a family with 2 biological parents. At 12-month follow-up, improvement in the SFSW intervention group was significantly greater compared with the control group on the following measures: CBCL/1.5-5 externalizing scale (effect size, 0.34; P < .001), internalizing scale (effect size, 0.35; P < .001), and total scores (effect size, 0.37; P < .001); 5 of 7 syndrome scales, including aggression (effect size, 0.36; P < .001), sleep (effect size, 0.24; P = .002), withdrawal (effect size, 0.25; P = .005), anxiety (effect size, 0.26; P = .003), and emotional problems (effect size, 0.31; P = .001); Inventory of Callous-Unemotional Traits callousness scores (effect size, 0.19; P = .03); and self-reported parenting skills (effect size, 0.53; P < .001). CONCLUSIONS AND RELEVANCE The study reveals the effectiveness and feasibility of an Internet-assisted parent training intervention offered for parents of preschool children with disruptive behavioral problems screened from the whole population. The strategy of population-based screening of children at an early age to offering parent training using digital technology and telephone coaching is a promising public health strategy for providing early intervention for a variety of child mental health problems. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01750996.

Distance Therapeutic Alliance: The Participant's Experience

Access barriers to services result in extensive wait times. Distance delivery systems with no face-to-face contact are not yet widely accepted because of uncertainty about whether therapeutic alliance can exist. In this study, 131 participants completed a questionnaire designed to explore their distance treatment experience. The majority described positive comments about the relationship formed with their telephone coach including the strength/quality, coach attributes, and the inapprehension to disclose information to the coach. Moreover, 97% reported preference for distance treatment. Acceptance and integration of evidence-based distance delivery systems are a promising approach to primary healthcare reform.

Better Nights/Better Days—Distance Intervention for Insomnia in School-Aged Children With/Without ADHD: A Randomized Controlled Trial

OBJECTIVE Better Nights/Better Days, a distance intervention for insomnia in school-aged children (with and without attention-deficit/hyperactivity disorder [ADHD]), was evaluated to determine its effectiveness on childrens sleep and psychosocial functioning. METHODS A single center, parallel group design randomized controlled trial (stratified on ADHD diagnosis) was conducted. Parents were randomized to intervention (n = 31) or waitlist control (n = 30), and completed questionnaires administered over the phone at baseline, postintervention (2 months), and follow-up (6 months). Actigraphy was also collected. The intervention consisted of a five-session manual and weekly telephone coach support. RESULTS The intervention group demonstrated a significant reduction in sleep problems and improved psychosocial functioning at postintervention and follow-up. Actigraphy results indicated improved sleep onset, but not sleep duration. Children with and without ADHD responded in a similar manner to this intervention. Parents provided high satisfaction ratings. CONCLUSIONS This intervention holds promise as an accessible, sustainable, and effective program to address insomnia in school-aged children.

Telehealth: a child and family-friendly approach to mental health-care reform.

Limited access to paediatric mental health services and high drop-out rates from treatment result in poor health outcomes for families with children with mental health problems. New ways of delivering care are required. Telehealth is a promising approach. The Family Help programme employs manualized, distance treatment by telephone. Participants in the Family Help programme (both adults and children) have reported a strong therapeutic alliance with their telephone coach. Participants also described how during treatment sessions they felt comfortable and safe in their own home; they did not feel stigmatized or judged; they had little apprehension about self-disclosure and they felt that treatment was delivered at their convenience. Treatment calls were often scheduled after typical working hours. Attrition rates were found to be very low and children actively engaged in the structured, distance treatment. Evidence-based, distance delivery using non-professionals is a promising approach to the delivery of paediatric mental health care.

A paediatric therapeutic alliance occurs with distance intervention.

We investigated whether a distance therapeutic alliance occurs when children receive manualized, cognitive-behavioural treatment via telephone, in the absence of face-to-face contact. The therapeutic alliance scores were measured in 55 child–parent pairs. The mean total Working Alliance Inventory child scores were 236 (95% confidence interval [CI]: 232, 240) and the mean parent scores were 245 (95% CI: 242, 247). Parent scores were significantly higher than child scores, although the difference may not be clinically meaningful. This study provides evidence that a strong therapeutic alliance does occur between child–coach and parent–coach pairs when treatment is delivered from a distance by non-professionals. The term ‘child’ encompasses both children and adolescents.

Barriers to mental health care: perceived delivery system differences.

Treatment barriers have prompted the development of new models of care. Distance delivery systems bridge the access gap, increasing service availability. Understanding differences between systems can inform system improvements. Sixty participants from the Strongest Families telephone intervention for child behavior difficulties participated. Participants completed a questionnaire to explore differences in perceived treatment barriers (Treatment Barriers Index—TBI) and therapeutic processes (eg, therapeutic alliance, self-disclosure, health outcome) between face-to-face versus distance treatment. The TBI scale has strong internal reliability (Cronbach &agr;: 0.95 [face-to-face]; 0.90 [distance]). Statistically significant differences were found between delivery system TBI mean scores, indicating fewer barriers with distance treatment. Therapeutic process differences between delivery modes suggest enhanced therapeutic alliance and self-disclosure scores with distance treatment. Increased access, convenience, and sense of privacy (visual anonymity) offered by a distance delivery system may provide an enhanced experience for some individuals.

Usability, learnability and performance evaluation of Intelligent Research and Intervention Software: A delivery platform for eHealth interventions.

Evaluation of an eHealth platform, Intelligent Research and Intervention Software was undertaken via cross-sectional survey of staff users and application performance monitoring. The platform is used to deliver psychosocial interventions across a range of clinical contexts, project scopes, and delivery modalities (e.g. hybrid telehealth, fully online self-managed, randomized control trials, and clinical service delivery). Intelligent Research and Intervention Software supports persuasive technology elements (e.g. tailoring, reminders, and personalization) as well as staff management tools. Results from the System Usability Scale involving 30 Staff and Administrative users across multiple projects were positive with overall mean score of 70 (“Acceptable”). The mean score for “Usability” sub-scale was 82 and for “Learnability” sub-scale 61. There were no significant differences in perceptions of usability across user groups or levels of experience. Application performance management analytics (e.g. Application Performance Index scores) across two test sites indicate the software platform is robust and reliable when compared to industry standards. Intelligent Research and Intervention Software is successfully operating as a flexible platform for creating, delivering, and evaluating eHealth interventions.

Exploring therapeutic alliance with an internet-based self-management program with brief telephone support for youth with arthritis: a pilot study.

Findings from a pilot study are presented exploring therapeutic alliance between adolescent juvenile idiopathic arthritis patients and a trained nonprofessional health coach during the feasibility testing of a 12-week self-management program delivered online with brief telephone support. Therapeutic alliance was measured using the Working Alliance Inventory Client Scale (WAI-C), and qualitative information about the experience was gathered using the Distance Experience Questionnaire. WAI-C scores were found to be comparable to previously published pediatric face-to-face data and pediatric distance treatment data. Therapeutic alliance scores were also found to be correlated with improved treatment outcomes (decreased reported pain).

Modeling Parenting Programs as an Interim Service for Families Waiting for Children's Mental Health Treatment

Using a discrete choice conjoint experiment, we explored the design of parenting programs as an interim strategy for families waiting for childrens mental health treatment. Latent class analysis yielded 4 segments with different design preferences. Simulations predicted the Fast-Paced Personal Contact segment, 22.1% of the sample, would prefer weekly therapist-led parenting groups. The Moderate-Paced Personal Contact segment (24.7%) preferred twice-monthly therapist-led parenting groups with twice-monthly lessons. The Moderate-Paced E–Contact segment (36.3%), preferred weekly to twice-monthly contacts, e-mail networking, and a program combining therapist-led sessions with the support of a computerized telephone e-coach. The Slow-Paced E–Contact segment (16.9%) preferred an approach combining monthly therapist-led sessions, e-coaching, and e-mail networking with other parents. Simulations predicted 45.3% of parents would utilize an option combining 5 therapist coaching calls with 5 e-coaching calls, a model that could reduce costs and extend the availability of interim services. Although 41.0% preferred weekly pacing, 58% were predicted to choose an interim parenting service conducted at a twice-monthly to monthly pace. The results of this study suggest that developing interim services reflecting parental preferences requires a choice of formats that includes parenting groups, telephone-coached distance programs, and e-coaching options conducted at a flexible pace.