Leveraging Technology to Address the Quality Chasm in Children’s Evidence-Based Psychotherapy

The mental health field needs scalable solutions to help improve clinical outcomes and close the gap between what is known and what is practiced in community service settings (1). Several studies have shown that the quality of psychosocial treatment delivery is highly variable in routine clinical care, even among well-trained providers (2). Many factors play a role, including provider experience, caseload diversity, children’s engagement, quality and frequency of provider training, funding streams, and organizational culture. Some of these factors are addressed in the context of large-scale dissemination initiatives to support sustained implementation of evidence-based psychotherapy (3–6). However, there are clear opportunities to leverage technology to build on these initiatives. One novel and understudied approach is the integration of technology-based resources that are designed to strengthen two important quality-of-care indicators: provider fidelity and children’s engagement (7).

Fidelity and engagement are prime targets for intervention because they are associated with children’s mental health outcomes in psychosocial treatment (8,9). Fidelity generally refers to the degree to which providers adhere to a treatment protocol and deliver it competently. Engagement reflects children’s general level of behavioral involvement in the treatment process. Providers encounter several barriers to sustaining high levels of fidelity and engagement in practice (10). They often manage large, diverse caseloads that require training and expertise in a wide range of treatments. This variability and complexity may threaten treatment fidelity and efficiency. A second challenge is the need to tailor treatment delivery to children’s developmental level, comorbid conditions, and cultural background (11). Ineffective strategies may steer providers away from the protocol and weaken quality of care. Third, children may be unwilling to speak openly to their providers or may resist discussing sensitive content or emotional and behavioral symptoms. Fourth, providers may communicate in ways that are not well matched to the learning styles of their patients (12). These examples underscore the potential benefits of innovative solutions that are designed to improve providers’ ability to deliver treatments with fidelity; engage children in treatment activities; strengthen the therapeutic alliance; support learning of new concepts, behavior, and skills; and improve patient-provider communication.

Studies in child education illustrate that touch-screen learning, interactive games, and video demonstrations enhance children’s engagement, learning, knowledge, and motivation (13). These benefits also may extend to the therapeutic context, where strategic integration of technology-facilitated interaction may improve child outcomes by strengthening the therapeutic alliance and helping providers deliver best-practice treatments with fidelity. Technology-based resources also may enhance children’s learning, which is particularly valuable in delivery of cognitive-behavioral treatment and other skills-focused approaches. Research is needed to examine these questions and direct the process of developing novel solutions. Do children learn more, or do they learn more efficiently, when psychoeducation is provided via game-based activities led by a provider as compared with more routine patient-provider interactions? How is the therapeutic alliance affected when technology is used to assist treatment delivery? Can expert video demonstrations designed to teach specific skills (such as behavior management techniques) to patients and caregivers enhance providers’ fidelity and competence and reinforce patient learning? Are children more likely to learn and show sustained use of skills learned via technology-enhanced activities versus traditional patient-provider interactions? These are important, unanswered questions.

The need for new resources and careful study is amplified by observations that mental health providers already have a head start on the integration of technology into practice. Many routinely search the Internet and software application (“app”) stores to identify videos and interactive tools that teach or reinforce a particular concept or skill. Providers often report positive reactions to these tools, and many believe that they have positive effects on children’s engagement and the quality of patient-provider interactions (10). However, research has neither directed nor carefully evaluated the use of these interactive tools in practice. Its impact on treatment engagement, completion, efficiency, and effectiveness is not yet known. Clearly, providers have an appetite for their use. Moreover, they have met recent efforts to develop, evaluate, and disseminate tablet-based “toolkits” with enthusiasm (10,14).

Case Example

This vignette is based on our experiences testing a tablet-based toolkit under a recently completed feasibility study funded by the National Institute of Mental Health (14). It is intended to be illustrative and does not necessarily reflect all children’s experiences with this approach.

“Michael,” a five-year-old boy, was enrolled in trauma-focused cognitive-behavioral therapy (TF-CBT), a components-based, evidence-supported treatment that is designed to address symptoms of posttraumatic stress disorder (including insomnia, nightmares, and hyperarousal), depressed mood, and disruptive behavior. Michael was experiencing many of these symptoms secondary to physical abuse. “Karen,” his mental health provider, used routine engagement strategies (positive reinforcement and emphasis on strengths) to build rapport. However, Michael was often unfocused and avoidant during his sessions, which interfered with learning and skill development and made staying on protocol and efficient delivery of treatment difficult for Karen. Michael would often ask to go to recess or to play hide-and-seek, or he would “act like a chicken” when Karen broached the subject of physical abuse and related life stressors.

In the early stages of treatment, Karen began using a tablet-based toolkit that consists of 11 activities (“chapters”) that were designed to facilitate delivery of TF-CBT based on guidance from children, providers, and expert trainers (7). Michael’s engagement in treatment activities increased considerably after the tablet toolkit was introduced. First, the provider played the “What Do You Know?” game with Michael, an interactive psychoeducation activity consisting of eight virtual decks of cards, each of which outlined questions and education and discussion aids relating to stressful and traumatic events. Michael and the provider took turns quizzing one another, for example, “If adults are fighting, what should a child do?” Michael was eager to answer questions in exchange for points. In a qualitative interview after participation in our pilot study, Karen described the “What Do You Know?” game as an activity that she used with many of her patients—including several who were not receiving TF-CBT—and added that it helps children “open up more” and helps providers “open up conversations with [children who] might have been difficult to approach.”

In the next session, Karen and Michael focused on developing relaxation skills using the “balloon game” chapter, an animated deep-breathing activity in which children keep pace with the speed of inflation and deflation and learn to transition from short and shallow breaths to slower, more deliberate breaths when they feel anxious. Michael followed along closely and demonstrated the technique properly. “Do I really breathe that fast [when I’m anxious]?” he laughed. Karen noted that her child patients enjoyed the balloon activity “more than any of the other ones” and attributed this to its simplicity and the ease with which providers and patients are able to do the activity simultaneously.

Next, the provider shifted to affective identification and processing by introducing a charades-style game where Michael and the provider took turns acting out emotion words that were selected each time Michael spun a virtual wheel on the tablet. They kept score, and Michael correctly identified several emotions and learned about other emotions with which he was unfamiliar. Karen reflected on her experiences using this activity. “I love the wheel. . . . I would play it with him, or I’d have [his] parents play it with him, or we’d all play together, and they kind of felt like it wasn’t just them having to do this. They weren’t in it alone.” Karen also shared favorable reactions to the parenting activity, which consisted of a series of videos designed to help providers teach behavior management skills. “The parenting videos were easy to use. With some parents, they learned about praising small things without adding a contingent ‘but’ at the end of the sentence. With a lot of my families [the videos] ended up giving them choices” with respect to how they might respond to undesirable behavior.

These and other tablet-based activities were used to help the provider deliver each TF-CBT component over the course of 13 treatment sessions. Michael’s symptoms improved significantly over the course of treatment. Whereas data from our qualitative interviews suggest a high level of acceptability and enthusiasm among children and providers, studies have not yet determined whether this approach and other technology-based activities improve clinical outcomes, children’s engagement, treatment efficiency, and provider fidelity (15). At the end of our pilot study, Karen was asked how the toolkit as a whole affected the way she conducted treatment with families. “It made it much easier. I didn’t have to work as hard. It made more sense for them instead of just going in with a worksheet. It made it more interactive, as well.”

Toward a Model of Technology-Enhanced Mental Health Treatment

Statewide and national dissemination and implementation initiatives have increased children’s access to best-practice treatment in recent years (8). However, these initiatives only partially address the quality chasm in children’s mental health care because many barriers interfere with providers’ ability to sustain high levels of fidelity after completion of the training process. Technology-based tools that are designed with the intent to improve and maintain high levels of treatment fidelity and facilitate patient-provider interactions are welcomed by providers and families and may help to increase quality of care and patient outcomes (10,14). Research is needed to examine their impact and potential for widespread adoption. Ideally, these tools should be designed to support the therapeutic alliance and enhance providers’ effectiveness and efficiency. Experts, providers, and children should guide development of these resources to ensure that they are relevant and engaging and that they facilitate treatment activities that are particularly challenging or difficult to navigate. The goal is not to take the place of therapeutic interactions as may occur with self-help interventions but to support children’s behavioral involvement and participation in treatment by making it more interactive and engaging and, one hopes, more effective. This, in turn, may enhance learning and skill acquisition, simplify navigation of challenging activities, and reduce treatment dropout, a pervasive problem in children’s mental health care (9,15).