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  • Advances in Computerized Interventions for Youth With Depressed Mood

  • 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  

    CABL logo

    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.

    SPARX protocol

    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.

    What About Parents?

    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 adolescent.

    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 Program

    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.

    If You Build it, Will They Come?

    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 support.

    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, Brown University.

    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.


    References

    Aguilera AM: There’s an app for that: Information technology applications for cognitive behavioral practitioners. Behav Therapist 2012; 35(4):65–67.

    Feil EG, et al.: Development and pilot testing of an internet-based parenting education program for teens and pre-teens: Parenting wisely. Family Psychol 2011; 27(22):22–26.

    Fleming TM, et al.: ‘It’s mean!’ The views of young people alienated from mainstream education on depression, help seeking and computerised therapy. Adv Ment Health 2012; 10(2):195–203.

    Merry SN, et al.: The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: Randomised controlled non-inferiority trial. BMJ 2012; 344(7857):1–16.

    Mohr DC, et al.: Supportive accountability: A model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res 2011; 13(1):136–146.

    Segal D, et al.: Development and evaluation of a parenting intervention program: Integration of scientific and practical approaches. Int J Hum Comput Interact 2003; 15(3):453–467.