by Anthony Spirito, PhD, and Jennifer Wolff, PhD
Computer-based technology is progressing
rapidly and has been applied to several
areas of service delivery as either an additive
or alternative to clinic-based therapy. For
children and adolescents, this approach may
hold promise in mental health treatments as
a means of increasing willingness to engage
in treatment. In addition to a computerized
program’s inherent appeal to children
and adolescents, some additional benefits
include ease of use, translatability to community
settings, potential reduced need for
transportation, and design flexibility of programs
to allow the child to pace themselves.
August 2013 Vol. 29, No. 8
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
In particular, cognitive behavioral therapy (CBT) may be well suited to computer-based administration because of its
structured and skills-based format. However,
the research evidence in support of
technology-augmented treatment is only
recently emerging. Two recently developed
programs are described below.
Sally Merry, MD, a child psychiatrist in
New Zealand, developed the Smart, Positive,
Active, Realistic, X-factor thoughts
(SPARX) protocol to treat depression among
adolescents. The protocol consists of a computerized
fantasy game designed to treat
adolescents with depression. Adolescents
select an avatar to represent them and
must defeat obstacles representing various aspects of depression in order to bring harmony
to the fictional world. The format
alters between using an instructional narrative
(in the form of a character acting as a
guide) and interactive challenges.
The avatar guide provides psychoeducation
on the nature of depression, assesses
the adolescent’s mood at regular intervals,
and assigns homework. Interactive challenges
include tasks such as shooting negative
thoughts and helping other characters
to solve problems. The following primary
skills are taught: 1) behavioral activation;
2) relaxation; 3) affect regulation; 4) problem
solving; 5) identifying and challenging
cognitive errors; and 6) relapse prevention.
In Merry’s first study, a waitlist-control
randomized controlled trial (RCT),
SPARX was evaluated for use among at-risk
youth from diverse socioeconomic backgrounds
with limited access to traditional
treatments (Fleming et al., 2012). Despite a
resistance to utilizing mental health care in
general, these adolescents reported interest
in SPARX and willingness to use it to
improve their moods. Adolescents using
SPARX reported a significant decrease in
symptoms of depression and more than twice the remission rate of the waitlist control
group (78% versus 36%).
A larger RCT comparing SPARX to
treatment as usual (TAU) included 187
youth with “mild to moderate depression”
referred by primary care physicians and
school counselors. Youth at risk for selfharm,
or who were judged as too severe to
receive self-help treatment, were excluded.
Adolescents using SPARX reported treatment
response rates comparable to TAU
(Merry et al., 2012).
Given that SPARX can offer access to a
broad range of youth at low cost, its comparable
efficacy to TAU is a compelling argument
in itself for consideration of computerized
interventions as a viable treatment
option. Because participants were recruited
from health care settings or schools and
primarily had mild to moderate symptoms
of depression, it is not yet known how more
severely depressed youth may respond to
this intervention. Therefore, the next logical
step is to evaluate its effectiveness with
clinic-referred children and adolescents.
With the exception of programs based in
schools, most, if not all, CBT protocols for
depressed adolescents include both parent
sessions and family sessions. Parent sessions
are necessary to help manage difficult
behaviors that often accompany depression
in adolescents. However, therapists often
struggle to find the time to deliver parent
content in addition to individual skills for
The use of technology may allow therapists
to better meet the needs of parents in
learning these much needed skills in a more
timely and efficient manner. If parents could
learn skills through a computerized program
then more time could be spent in the treatment
of the adolescent. Of course, the opposite
might also be true: parents might need
more time in-session than the adolescent.
Consequently, an integrated technology
approach would include technology geared
toward both the adolescent and parent.
Parenting Wisely (PW) is a computerized
parenting program that consists of 9
modules that address how to handle common
parenting problems such as enforcing
chores, monitoring friends, improving
school performance, and handling sibling
conflicts. All 9 sessions can be completed in
2 to 3 hours. The program has the advantage
of being easily personalized by allowing
each family to choose specific modules to review. Based on social learning, cognitive behavioral,
and family systems theories,
the program is designed to improve parent–child communication skills as well as
parental disciplinary skills.
The original PW program was designed
for adolescents at risk for, or already engaging
in, problem behavior, such as substance
abuse and truancy. Parents can use this self-instructional
program in a clinic office or at
home, using an online format. During each
session, a video of a typical family problem,
such as being late for a curfew or finding
drugs in an adolescent’s room, is shown and
then parents choose from a list of possible
solutions with differing levels of effectiveness.
After a solution is chosen, a video of
the solution is displayed and each solution
is critiqued through interactive questions
and answers. Each session ends with a quiz.
Parents also receive workbooks containing
parenting strategies as well as exercises to
promote skill building and practice.
Preliminary efficacy for the online version
of PW was recently examined among a sample
of 65 multiethnic families with behavior
problem children (Feil et al., 2011). Results
demonstrated effect sizes within the small
to medium range on all parenting behaviors.
Further, parents demonstrated a high level of
satisfaction with the computerized program.
In another study, the developer of PW
evaluated mandatory use of PW with court-referred
low-income parents of juvenile
delinquents compared to a matched control
group of youth who received probation
services. Adolescents in the treatment group showed a 50% reduction in problem
behavior and gains were maintained at 1-,
3-, and 6-month follow-ups.
Similarly, in a randomized study with
parents in outpatient clinics and a residential
treatment center, Segal et al. (2003)
found that use of PW was associated with
significant decreases in the number and
intensity of child problem behaviors.
Reaching and engaging parents and adolescents
in treatment programs for depression
is important given that many adolescents
in need of treatment do not receive
or drop out of treatment prematurely.
Although developing new and better technologies
will advance the field, it is equally,
if not more, important to study ways to
ensure use of these technologies by our
patients. For example, in the general population,
one month after their download,
only 38% of phone apps are opened more
than once and one
can imagine this is even lower in adolescents
in general and adolescents seeking
mental health care, in particular.
The true challenge therefore is not
developing new and exciting technologies
but the “need for collaborative techniques
to enhance and maintain usage in vivo
to improve therapy outcomes” (Aguilera,
2012). Studies (e.g. Mohr et al., 2011) have
shown that technological interventions are
improved when combined with in-person
Such integration is not necessarily intuitive
so exploring the most feasible and acceptable means of integrating technology
into CBT for depressed adolescents is a necessary
next step in the evolution of computerized
approaches to the treatment of clinicreferred
adolescents and their parents.
Anthony Spirito, PhD, is professor of psychiatry and human behavior at The Alpert Medical School,
Jennifer Wolff, PhD, is staff psychologist
at Rhode Island Hospital, the director of the
Adolescent Mood Clinic, and assistant professor of
psychiatry and human behavior at The Alpert Medical
School, Brown University.
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