What is the problem that needs to be addressed? Please describe how it is related to mental health.
Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent childhood psychiatric condition, affecting nearly 1 in 10 children in the United States, with a profound public health, personal, and family impact. Recent estimates put the annual cost of ADHD as high as $266 billion, much of which is lost productivity and income for adults with ADHD and parents of children with ADHD. ADHD requires comprehensive treatment, including child interventions (e.g., behavioral treatment, medication), parent training, and educational planning. Because ADHD is chronic and lifelong, maintenance, which requires substantial self-regulation, is needed to support initial treatment gains. Our goal is to enhance self-regulation and self-efficacy in parents by prompting them to implement therapeutic strategies and to reflect on their progress. Traditional methods of mental health intervention cannot address this need. Group parent training loses effectiveness over time, paper and electronic parenting materials are likely to be discarded, and in-person therapy with a clinician does not scale over the long-term for every family and is very costly and places a high burden on the mental health system. When diagnosed or undiagnosed behavior problems in children are considered alongside ADHD, the problem is even more daunting. Innovative mental health approaches are desperately needed.
Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Given the chronic and pervasive impairments associated with Attention Deficit Hyperactivity Disorder (ADHD) and related behavior disorders, high rates of child comorbidity, and heightened problems in social interactions and relationships, children with ADHD and behavior problems are at risk for poor outcomes and require intensive interventions. Among Latino and other minority underserved children with ADHD, there are well documented health disparities and unmet clinical needs, suggesting that their risk of poor outcomes may be even more concerning. Culturally relevant and easily accessible interventions are urgently needed.
Self-regulation is a robust predictor of positive outcomes in adulthood, and early childhood is a critical period for developing self-regulation. Young children (ages 3-7) with poor self-regulatory skills have been described as “at-risk” for ADHD. Many parent training interventions across the United States and world have attempted to address the need for culturally relevant and accessible interventions to build self-regulation during a “critical period” of development. For the last fifteen years, we have delivered one of these programs in Southern California. The success of these mental health interventions in improving child self-regulation, improving parenting skills, reducing parenting stress, and reducing barriers to service for underserved families have all been documented in our prior research. However, despite initial success, like most other mental health interventions, long-term maintenance is challenging, gains are lost over time, and new solutions are needed. We are now developing and testing such solutions.
What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Although health IT applications are growing across the United States, this work has not yet addressed behavioral disorders and ADHD in young children, particularly among underserved and minority children. Our research builds on the growing body of work using mobile platforms for healthcare interventions. For example, text messaging has been used to support smoking cessation programs, cognitive behavioral therapy, and adherence to appointment schedules. More advanced applications allow clinicians to monitor adherence to behavioral protocols, monitor and detect cardiac events, and support patients in monitoring their own physical activity levels. These approaches are particularly applicable for chronic health conditions, in which people are highly motivated to engage with a variety of therapeutic options. Early research in the use of smartphones in mental health is also promising. Smartphones have been used to support real-time self-reporting of mood states. Additionally, use of mobile phones may enhance communication when patients find the topics too difficult to discuss in person. Data collected via mobile phones can be visualized and paired with external data, such as location, to raise awareness of emotional states in individuals and encourage adherence to prescribed treatment. Our research team recently received the first award from the federal Agency for Healthcare Research and Quality focused on the development of health IT solutions for teenagers with ADHD and behavioral disorders. No one has yet applied such technology to parents of young children at risk for ADHD and behavioral disorders, in spite of the fact that early childhood is such a critical time for the development of self-regulation.
What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Wearable computing and the Internet of Things have made truly low-cost, highly customized innovative interventions possible and are expected to take giant leaps in the next ten years. These approaches provide innovative health IT mechanisms for delivering long-term follow-up interventions that enhance and reinforce treatment, improving outcomes and reducing the burden on public mental health systems. Our multidisciplinary, clinical research team has extensive experience developing ADHD, behavior disorder, and technological interventions. Here we propose to develop and test a novel technology that will use a wearable and connected system that combines a fitness and health tracker, mobile phone app, and web portal with an online community, which can be used to deliver intervention and improve maintenance over time for parents of children at risk for ADHD or related behavioral disorders. Our multilingual team is able to develop and test the intervention in both English and Spanish, and future efforts could translate materials into other languages as needed.
Families of young children at risk for ADHD have complex needs. Despite improvement in outcomes following family interventions, long-term maintenance is a challenge unmet by traditional medical approaches. The key innovation in our research is use of novel but low-cost and highly available technologies to create a sustainable solution for supporting long-term maintenance. This research will fill a major gap in the translation of early prevention or treatment investments and gains into long-term, sustainable outcomes.
Culturally Relevant Family Interventions. Previous efforts have not yet considered the context of culturally relevant family interventions, the focus of our work. While enrolled in parent training, parents are instructed to practice what they learn outside of the therapeutic session. Thus, our system, which is geared towards direct use by parents, must also ensure that parents’ needs are addressed. To accomplish these goals, we will incorporate feedback from parents and clinicians in our design and ensure that our health IT intervention delivers accessible health and behavioral information, prompts, and feedback to improve response to treatment.
Technological Innovation. Our IT solution is innovative in three key ways. (1) Although other projects have used self-reported data collection through ecological momentary assessment or via video, email, and SMS capabilities of a smartphone, we will use automatically recorded data from a variety of sensors visualized alongside self-reported data. These data will be visualized with self-report data to enhance parents’ abilities to reflect on their experiences. (2) Our solution leverages the full range of wearable technology and smartphone (Android and iOS) capabilities to provide interventions that are more interactive and engaging than the simple text-based messaging that has dominated previous research. (3) The assemblage of commodity off the shelf hardware in new and innovative ways to create a unique experience for parents will ensure the adoption and sustainability of our approach.
What is the project idea? Please describe how this project will operate.
To address the complex behavioral and mental health needs of parents coping with a child’s poor self-regulation and to contribute to scientific and broader clinical knowledge about improving treatment adherence and outcomes, our project is designed to adapt a technological intervention to an unmet clinical need among underserved families. Our first aim is to conduct design workshops over six weeks with four cohorts, each consisting of 4 to 6 parents and clinicians. We will recruit a diverse sample of affected parents and community clinicians to participate in focus group research addressing design elements to ensure that robust feedback from potential users is incorporated from the start. With cooperative design, we will finalize the requirements, user experience, and details of the hardware and software to inform the design and functionality of the IT solution. We will create a wearable, context-aware system for supporting long-term change that will include three core modules: educational information, data collection, and data visualization. Our second aim is to evaluate the effectiveness of the IT solution. We will recruit six cohorts, each consisting of 20 families (N=120) of children ages 3-7 who are at-risk for ADHD (i.e., meet criteria for poor attention and self-regulation). All families will receive parent group intervention; half will be randomized to receive standard in-person group intervention (comparison group representing current approaches), and half will participate in intervention supplemented with our IT solution. Participants will be followed for one year to evaluate the impact of the health IT solution on treatment gains. To measure psychological (e.g., parental stress, child self-regulation) and biological (salivary cortisol and alpha-amylase, biomarkers of parental stress) outcomes we will use a mixed methods evaluation at four time points with all families: (1) pre-intervention, (2) after completion of the 10 week in-person intervention, (3) six months after completion of the in-person intervention, and (4) one year after completion of the in-person intervention. This proposed project could provide important contributions to field of mental health, both in Orange County and beyond, as it will provide a model for incorporating innovate IT solutions to improve mental health outcomes.
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