Behavioral Parent Training: Is There an “App” for That?

It is certainly not true that everyone owns an iPhone (yet!), but rare is the individual who has not heard the commercials with the catchy phrase, “There is an ‘app’ for that.” For many, “apps,” or applications, may be synonymous with the iPhone. So familiar are iPhone applications that a full-page advertisement is now being run in national newspapers with the headline, “Introducing 16 apps that need no introduction.” So, what exactly is an “app”? “Apps” are simply software programs that most recently have become synonymous with those developed for download to a range of smartphones (e.g., Blackberry, iPhone, Droid). “Apps” involve a variety of functions, depending on the particular program, with some more sophisticated than others. For example, there is now an application for tracking packages with an express carrier. Another application allows one to check whether an item is in stock at a popular retailer. Still another application not only gives directions to a ubiquitous coffee shop, but also allows the user to add money to a customized card before arriving. There are literally applications available to manage almost every aspect of one’s life, but what about parenting? … Is there an “app” for that?

Although unlikely to be highlighted on the famous “There is an ‘app’ for that” commercials, there are many applications that have been developed that are related to the field of behavior therapy. Simply typing “psychology” into the iPhone “App Store” yields hundreds of related applications, ranging from one that assesses the user’s personality to another that aims to boost happiness in times of stress. A more narrow search for “behavior therapy” yields far fewer applications; however, there are still many of relevance, including applications that target the fear of flying, help to better manage time, assist with assertiveness training, and even an application that guides recording automatic thoughts and labeling cognitive errors.

There are also “apps” that focus on issues of relevance to behavioral parent training for child disruptive behaviors. There are less applied applications like the one to help parents assess their own parenting style, an exercise that parallels, although certainly less rigorous, the assessment phase of behavioral parent training. There are also more practical applications, including several designed to guide parents through the use of time-out. When the child’s behavior merits a time-out, the parent can click on the child’s name, which they have previously entered, and the application will tell them how long the time-out should last based on the child’s age (which was also previously entered) and serve as a timer. To our knowledge, there is no available empirical data that would tell us whether such an application was helpful to parents or not. Are parents who use the time-out application more effective with the time-out procedure and, therefore, more likely to stick with it, than parents who do not? Our educated guess is that although the various time-out applications at first glance may seem helpful to parents, they have little impact on parent’s competence in their use of time-out or confidence in carrying out the procedure. That is, the most difficult part of time-out for parents is likely not calculating the number of minutes the time-out should last or even finding a timer. Rather, the more difficult part of time-out for parents is determining whether time-out is the most appropriate consequence to use at a particular time: then, if it is, remembering the timeout sequence, remaining calm but firm during its administration, and utilizing the consequence consistently. These are not simple things for parents to learn and success requires significant in- and out-of-session practice—a commitment to which the barriers often seem insurmountable to many parents.

Behavioral Parent Training: Engagement and Retention

Years of accumulated data suggest that behavioral parent training, which includes time-out as well as other skills (e.g., rewards, ignoring, giving effective instruction), works—parenting behavior improves and, in turn, child behavior problems decline (see Eyberg, Nelson, & Boggs, 2008; Kazdin, 2000, for reviews). As highlighted elsewhere (Prinz & Sanders, 2007), numerous obstacles preclude many families from accessing empirically supported behavioral parent training programs (e.g., lack of knowledge that such programs exist; limited availability of trained clinicians). Even if a family is referred to a clinician who is trained to offer behavioral parent training, most empirically supported programs are relatively time-intensive, requiring both in-and out-of-session practice, a commitment that may be daunting to many already stressed families (Prinz & Sanders, 2007). The potential burden of this investment cannot be underestimated (Ingoldsby, in press; Prinz & Sanders, 2007) and is a primary challenge to the effectiveness of behavioral parent training. Inadequate engagement in behavioral parent training leads to family attrition, which has been estimated to be more than one-fourth of parents in parent training research (Forehand, Middlebrook, & Rogers, 1983; Sanders, Markie-Dadds, & Tully, 2000). Failure to engage in services also decreases the likelihood that parents who do continue to attend will adequately learn effective parenting skills (e.g., Jensen et al., 1999; Nock & Ferriter, 2005). Parental lack of confidence and competence in the new skills increases the likelihood that both parents and children will return to old patterns of behavior (i.e., the coercive cycle proposed by Patterson; see Granic & Patterson, 2006; McMahon & Forehand, 2003).

So, what are the consequences of parents failing to engage in, and ultimately dropping out of, parent training programs? Many of the children whose parents seek treatment are on the “early starter pathway,” which is associated with the worst prognosis for youth (see McMahon & Forehand, 2003). This pathway is characterized by the onset of relatively less serious conduct problems in the preschool and early childhood years, most notably noncompliance, and progression without treatment to increasingly serious conduct problems (e.g., aggression, stealing, substance use) throughout childhood, adolescence, and adulthood (Calkins & Keane, 2009; Frick & Viding, 2009). Parents play a critical role in the early starter model with regard to how they respond to early noncompliant behaviors and are considered a primary mechanism by which children accelerate along an early starter pathway (McMahon & Forehand). As a consequence, behavioral parent training is a treatment of choice for early starter pathway families (Granic & Patterson, 2006; McMahon & Forehand). If parents fail to engage in, and ultimately drop out of, parent training, children will be at a substantially higher risk for remaining on a pathway to serious conduct problems (e.g., McMahon & Forehand).

Promoting Engagement and Retention: The Role of Technology

Given the public health importance of treating early starter pathway youth and their families, what strategies have been used to enhance parental engagement and, in turn, increase the likelihood that they will be retained in the program a sufficient length of time to benefit from the skills training? As summarized elsewhere (Ingoldsby, in press), previous strategies include the following: appointment reminders (e.g., Watt, Hoyland, Best, & Dadds, 2007), identifying and overcoming barriers to treatment (e.g., McKay, Stoewe, McCadam, & Gonzales, 1998), monetary incentives (e.g., Heinrichs, 2006), building relationships and addressing resistance prior to therapy (e.g., Szapocznik et al., 1988), family support (e.g., Miller & Prinz, 2003), and motivational techniques (e.g., Nock & Kazdin, 2005; Sterrett, Jones, Zalot, & Shook, in press).

While some of these approaches have shown promise for improving the engagement of families, others have yielded fewer, if any, gains (Ingoldsby, in press). Moreover, the programs that show promise largely represent the development of new programs designed to explicitly address the issue of engagement (e.g., Szapocznik’s Strategic Structural Systems Engagement; Nock & Kazdin’s Participation Enhancement Intervention); in contrast, little attention has been given to innovative enhancements for existing behavioral parent training programs. We propose that one particularly innovative approach for moving the field forward is the inclusion of technological enhancements to existing parenting programs.

How can advances in technology help? Alan Kadzin (2008), the former President of the American Psychological Association and ABCT and a well-known researcher in the field of behavioral parent training, noted there is a relatively untapped potential of various telecommunication technologies to enhance the effectiveness of treatments by maintaining connections with clients beyond the walls of the therapy room. Importantly, smartphones integrate the benefits of a wide range of technologies (i.e., telephone, computer, electronic organizer) into a portable and relatively cost-effective hand-held device, allowing users wireless access to phone, e-mail, web, and videos. Users are able to synchronize and transfer information between their smartphones and other technologies (e.g., internet, computers, etc.), send and receive email and text messages, and even send and receive video.

Can technology increase parental engagement in behavioral parent training and, in turn, prevent parent dropout? Self-Determination Theory (SDT; Ryan & Deci, 2000) would suggest that it can. SDT posits that human motivation falls along a continuum. The least self-determined motivation, external motivation (i.e., the propensity to engage in a particular behavior to satisfy an external requirement), falls at one end of the continuum (e.g., court-mandated parenting classes), while the most self-determined motivation, intrinsic motivation (i.e., the tendency to engage in a behavior due to the pleasure of and interest in the behavior itself), falls at the other (e.g., enjoying new parenting skills; Deci & Ryan, 2002; Ryan & Deci, 2000). Importantly, intrinsic motivation is considered the most likely to fulfill the most basic of psychological needs: autonomy (i.e., need for control), competence (i.e., need for effectiveness), and relatedness (i.e., need for relationships). Given that intrinsic (autonomous) behaviors are most likely to meet individual psychological needs and, in turn, are most likely to be maintained over time, autonomy and support for autonomy have been considered critical to behavior change interventions (e.g., Williams, Lynch, & Glasgow, 2007).

Building upon SDT (Ryan & Deci, 2000), the incorporation of smartphone technology into parent training can potentially enhance engagement and retention in several ways. First, smartphones could afford therapists the opportunity to provide more support to parents by providing intervention options outside of the therapy setting (e.g., home). Therapists could provide additional out-of-session information to the families about the program (e.g., sample skills video to watch on smartphones; text message reminders about skills practice). In addition, families could receive more informed feedback from therapists based on their out-of-session practice of skills (e.g., daily assessments, weekly check-ins, videotaped skills practice). By increasing the family’s relationship with the therapist, as well as the accessibility of the program to the family, smartphones could enhance the parents’ overall positive feelings about the behavioral parent training program. Although initially the smartphone may promote greater reliance on the therapist (i.e., less autonomy), the increased opportunity for connection and practice could afford a means for parents to feel more competent in the use of the new skills both in and out of session and to reach criterion on each of the parenting skills more quickly (i.e., more autonomy) (e.g., Williams et al., 2007). In turn, parents may require fewer sessions to reach criterion on each of the new skills.

Relative to the potential advantages, prior research suggests that incorporating smartphones into existing parent training programs should produce little additional family burden. Estimates of burden are not yet available for behavioral parent training in particular; however, research using cellular phones with other difficult-to-engage groups (e.g., homeless, HIV-infected) suggests a high level of satisfaction, including programs that ask participants to carry phones at all times and to receive calls at random intervals (Collins, Kashdan, & Gollnisch, 2003). In addition, when cellular phones are used, the majority of participants (95%) complete the intervention, again suggesting the burden of the technology is minimal (Alemagno et al., 1996).

Economic burden must also be considered. It would be remiss to ignore the potential costs (e.g., cost of smartphone, service plan) or practical issues (e.g., service coverage) associated with using smartphones. Importantly, industry estimates suggest that 40 million smartphones or wireless enabled personal data assistants (PDAs) were being used by Americans in 2009 (CTIA, 2009). The increase in smartphone use, occurring at the same time that the sales of cellular phones more generally is on the decline, has been attributed to economics (Lohr, 2009). Smartphones bundle the advantages of other types of technology, affording the user the opportunity to make telephone calls, text, and access the web. Furthermore, most Americans live in areas with multiple wireless service providers (CTIA, 2009). As more of these and other companies provide smartphone options, prices have begun and will continue to drop, leading to more accessibility across income levels. In fact, technology experts have suggested that the next wave of users will be lower-income consumers because they can acquire the benefits of the Internet without the operating system or cable package required for at-home use of a desktop computer (Noyes, 2007). Thus, in the near future, smartphones may well be an economical and readily available way to promote engagement and retention.

Conclusions

So, back to the question: Is there an “app” for behavioral parent training? The answer currently is “no,” but theory, research, and decreasing costs suggest that will soon change. In anticipation of the decreasing cost and growing use of smartphones, now is the time to begin to capitalize on and to empirically test the utilization of smartphones for enhancing the engagement and retention of families in behavioral parent training programs. Consistent with Kazdin’s (2008) call for more attention to technology innovations, as well as a similar call by the National Institute of Mental Health (2003), we are currently developing the components of an application for the iPhone aimed at increasing the engagement and retention of parents in one well-established behavioral parent training program, Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003).

Through the use of iPhones, we plan to utilize several strategies with parents that have been used in behavioral parent training, as well as other interventions, including the following: to upload printed HNC materials from the manual; to conduct between-session telephone check-ins with parents (e.g., McMahon & Forehand, 2003); to provide parenting skill video demonstrations (e.g., Sanders et al., 2000; Webster-Stratton, 1994); to email and text message reminders regarding skills practice (e.g., Andersson, Strömgren, & Ström, 2002; Celio, Winzelberg, Dev, & Taylor, 2002); and to conduct daily assessments of skills practice (e.g., Fung, Menassis, & Kenny, 2002). In addition, iPhones will provide the opportunity for parents to videotape their daily in-home skills practice for review with the therapist, providing increased opportunity for therapist observation and feedback on progress on each of the skills. Of importance, our aim is not to replace weekly telephone check-ins or face-to-face weekly sessions with the therapist; rather, the iPhone will allow us to integrate the advantages of multiple technologies into one portable device to enhance parental engagement in the program by forging a virtual connection between the parent, the HNC program, and the therapist.

Beyond engaging the participating parent, usually the mother, iPhones also can help to assess and include in treatment other adults and family members (e.g., co-parents) assisting the mother with parenting. Given that these coparents are unlikely to attend the intervention sessions (McMahon & Forehand, 2003), we plan to use iPhones to promote their involvement in several ways: to text-message reminders to parents that coparents should be using the skills as well; to gather information on the extent to which coparents are also practicing the skills at home; to encourage mothers to share videos of skills demonstrations with coparents; and ask mothers to videotape coparents’ skills practice.

There are several aims to this initial pilot investigation. First, our goal is to examine the extent to which families who we already know may have difficulty engaging in behavioral parent training utilize the iPhone-enhanced HNC components of treatment. Therapists will have a record of whether or not each participating family is completing the daily assessments on the iPhone, as this information will be directly uploaded to a therapist spreadsheet when the family completes the iPhone survey. Families will also be asked to bring their iPhones to session each week, so the therapists will know via a counter embedded in the videos the extent to which the videos have been watched, how many times they have been watched, and whether or not families have videotaped their skills practice. Finally, families will have an opportunity at the end of treatment to complete a consumer satisfaction questionnaire that will assess satisfaction with the iPhone intervention components, as well as recommendations for improvements that would better meet family needs.

Asking mothers to videotape their own skills practice using the iPhone may seem like a potential challenge. However, small tripods that have been designed for use with the iPhone are now available and are relatively easy to use, suggesting that once we show parents how to set up the phone and start and stop the video, this may actually be a relatively easy way for them to get informed therapist feedback on their daily skills practice. Importantly, the consumer satisfaction questionnaire, as well as weekly therapist-mother interaction, will provide more definitive information on the feasibility of all aspects of the iPhone intervention components. Our hypothesis, however, is that parents will engage in these relatively brief mini-assessments and interventions, which, coupled with the daily reminders, standard weekly telephone check-in, and standard weekly session, will yield higher levels of engagement throughout the course of treatment, fewer sessions to reach behavioral criterion for each of the HNC skills, and reduction in dropout from the program. Furthermore, we will examine if co-parents (e.g., fathers, grandmothers) of mothers engage more in the HNC treatment program, increasing the likelihood that mothers will feel supported and remain engaged, eventually benefitting their children, as well as identify any obstacles to co-parent engagement in the iPhone intervention components (e.g., watching skills videos, videotaping their own skills practice) that could guide the improvement of the eventual application. Finally, we will conduct cost-effectiveness analyses, which we expect will show that the costs of iPhones will be outweighed by the benefits (e.g., fewer sessions to reach criterion for the acquisition of the parenting skills).

Once the component parts of the application are tested as a package and, assuming their use is supported, and modifications are made consistent with family feedback, the next step will be to develop the “app” that can complement the HNC manual, providing an additional resource for therapists and the families with whom they work. While our focus is on the use of an HNC application to enhance engagement and retention of families in behavioral parent training, the components of the application likely have utility in their own right as well (e.g., streamlined assessment strategies, increased opportunity for therapist observation of skills practice; efficient strategies to remind parents about skills practice). And maybe, someday, one of those commercials will say, “Behavioral parent training … there is an ‘app’ for that.”