Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Abstract

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Telepsychology and mobile health (mHealth) services (referred to throughout as TPmH) have increased in prevalence during the COVID-19 pandemic in response to social distancing guidelines, stay-at-home orders, and escalating mental health needs (Figueroa & Aguilera, 2020; Wosik et al., 2020). TPmH, which broadly involve the remote provision or enhancement of psychological services via electronic transmission of information (American Psychological Association, 2013; Clough & Casey, 2015), are artifacts of the current digital age of psychology. With the rapid transition to these virtual platforms during the pandemic, understanding the effectiveness of TPmH interventions has become a key research priority for the mental health field. Despite nearly two-thirds of youth in the United States (U.S.) having used some form of TPmH apps for managing mental health and other health behaviors, evidence of their effectiveness is mixed, and even less is known about the uptake and effectiveness of these interventions among racial-ethnic minoritized (REM) youth and families (Psihogios et al., 2022; Rideout et al., 2018). While TPmH may increase access to care for some populations, such as clients in rural communities (C. Chu et al., 2021), they may also introduce new barriers to accessing and engaging in mental health services, especially if interventions are not responsive to clients’ unique cultural backgrounds (Schueller et al., 2019). Now, more than ever, it is critical that we approach the development, design, and implementation of TPmH interventions from a culturally responsive lens to ensure that these services do not fall prey to the same pitfalls that that have plagued the development of in-person evidence-based treatments, including the research-to-practice gap (Psihogios et al., 2022; Rideout et al., 2018).

This manuscript begins with a brief review of extant literature on TPmH, followed by a discussion of culturally responsive or culturally-adapted evidence-based treatments or interventions (EBTIs) in REM youth and families. Next, we discuss the small body of work that has integrated these two fields of study to develop and test culturally adapted TPmH. These sections focus on psychosocial interventions due to a relative dearth of data on psychological assessment development and implementation using TPmH in both youth and adults (for a recent review of neuropsychology assessment via TPmH see Van Patten, 2021). Following this brief review of the literature, we provide concrete recommendations that will help to improve the development and implementation of culturally responsive TPmH for REM youth and families. We focus specifically on the U.S. given that differing sociocultural, economic, and political factors in other countries pose additional considerations for culturally responsive TPmH.

Overview of Telepsychology and mHealth

Telepsychology falls under the umbrella of telehealth – the remote provision of healthcare via transmitting information electronically over distance (Nickelson, 1998) - and specifically refers to the provision of psychological services through this medium, including via telephone calls, video conferencing, text messaging, and mobile applications or “apps” (American Psychological Association, 2013). Although the terms telepsychology and mHealth are sometimes used interchangeably, psychological interventions delivered via mHealth more typically refer to mobile and wireless technologies other than telephone or video calls, such as apps, text messaging, passive sensing, wearable devices, and social media interventions (Clough & Casey, 2015).

Notably, there is significant heterogeneity in TPmH, with variability in the modes of treatment delivery, degree of therapist involvement, intensity of contact, service location, and more. Regarding modes of delivery, a variety of tools exist, including synchronous video conferencing or telephone calls, text messaging (e.g., automated, sent by a provider), mobile apps, interactive and non-interactive websites, games and other computer-assisted programs, virtual reality, and wearable devices (Hollis et al., 2017; Liverpool et al., 2020). Synchronous video and telephone calls for youth have received significantly more research attention than other TPmH interventions (Hollis et al., 2017). TPmH can be used to augment in-person services (e.g., apps for symptom tracking), or as stand-alone interventions. There is also variability in the degree of therapist involvement or support within these various modalities. For example, a review of internet-delivered cognitive behavioral therapy for youth found that 21 of 25 studies included some form of therapist support through written messages, a combination of written messages and phone calls, or face-to-face contact; the remaining four studies included no therapist support or contact during the intervention (Vigerland et al., 2016). TPmH interventions vary in intensity, ranging from single-session, self-guided internet-based interventions (e.g., Schleider et al., 2020) to multi-session treatment protocols (e.g., Nelson et al., 2003). TPmH have been implemented in various settings, including academic medical centers, outpatient mental health clinics, pediatric psychology settings, substance use rehabilitation facilities, and K-12 schools.

While TPmH interventions were first developed for and tested in adult populations, they have since been adapted for use with youth and their families, with the majority of research in this area focusing specifically on middle childhood (Nelson et al., 2017). Although TPmH for youth were initially intended to increase access to care for residents of rural areas, they have been expanded to support youth in urban areas as well (Nelson & Sharp, 2016). Research has shown that TPmH are feasible and potentially efficacious for youth with a range for mental health disorders including attention deficit/hyperactivity disorder (ADHD; Tse et al., 2015; Xie et al., 2013), anxiety (March et al., 2018), depression (Nelson et al., 2017), disruptive behavior disorders (Comer et al., 2017), depression (Nelson et al., 2017), substance use (Murry et al., 2019), and eating disorders (Anderson et al., 2017), among others. Several recent reviews provide an overview of outcome data on TPmH for youth (see: Hollis et al., 2017; Nelson & Sharp, 2016; Ros-DeMarize et al., 2021; Slone et al., 2012; Van Allen et al., 2011). However, despite an increasing number of studies examining the efficacy and effectiveness of TPmH in youth, research in this area has predominantly been conducted with non-Hispanic White youth and families and has consisted of smaller uncontrolled trials. Thus, questions remain regarding the relevance and effectiveness of telepsychology and mHealth services for REM youth (Ramos & Chavira, 2022). Prior to reviewing the small body of research on culturally adapted TPmH interventions, we set the foundation for this discussion by providing a brief overview of culturally-adapted face-to-face EBTIs for youth.

Overview of Culturally-Adapted EBTIs for Youth/Families

Calls for Culturally-Adapted EBTIs

In recent decades, as EBTIs have gained popularity and traction, increased attention has been paid to their generalizability in community settings with diverse populations. Similar to TPmH, the vast majority of EBTIs were initially developed and tested with non-Hispanic White children and families (Southam-Gerow et al., 2003). While there has been some progress to correct the issue of representation, REM youth and families continue to be underrepresented in clinical trials today (Cook et al., 2017). In addition to having suboptimal representation, the generalizability of these often highly structured interventions has been scrutinized by implementation scientists. Typically developed in controlled laboratory settings, these interventions are often not reflective of community realities where crises occur often (Lau et al., 2018), families face multiple presenting problems (Ehrenreich-May et al., 2011; Fernandez et al., 2011), and providers contend with high caseloads, stress, and burnout (Kim et al., 2018). Striking evidence of racial and ethnic disparities in access to services (Barnett et al., 2019; Henry et al., 2020; McGuire & Miranda, 2008) and outcomes within services (e.g., poor engagement and symptom reduction, higher dropout rates; Alegria et al., 2010) highlighted additional need for improvement. In response to these historical trends, calls within clinical science were made to make EBTIs more suitable in community settings with diverse populations (Forehand & Kotchick, 1996; Lau, 2006). One outcome of the calls to focus on disparities was to study the adaptations of EBTIs when delivered with REM populations. Although making adaptations may be an imperfect approach to developing relevant interventions for REM youth and families, it allows for cultural values, variations in worldviews, and differences in language to be incorporated into treatment. While it is outside the scope of the current manuscript to systematically review all current examples of cultural adaptations to EBTIs (see Arora et al., 2021), this brief review will highlight historical trends in theoretical frameworks for cultural adaptation, provide examples of adapted EBTIs for youth and families, and outline important considerations for the next generation of TPmH research with REM youth and families.

Existing Frameworks of Cultural Adaptations

Cultural adaptations to EBTIs have been defined as the “systematic modification of an EBT or intervention protocol to consider language, culture, and context in such a way that it is compatible with a client’s cultural patterns, meanings, and values” (Bernal et al., 2009, p. 362). A recent systematic review of culturally adapted EBTIs for REM youth (Arora et al., 2021) found that the most common theoretical frameworks guiding cultural adaptations were the Ecological Validity Model (Bernal et al., 1995), the Cultural Adaptation Process model (Bernal et al., 2009; Domenech-Rodríguez & Wieling, 2004), and surface structure versus deep structure adaptations (Resnicow et al., 1999). The Ecological Validity Model (Bernal et al., 1995) proposes adaptations to eight dimensions of an intervention: language (translations, culturally syntonic language), persons (relationship between therapist and client), metaphors (symbols or concepts shared by a group), content (values, customs, and traditions), concepts (theoretical orientations), goals (target outcomes), methods (ways of achieving target goals), and context (acculturation, developmental stage, social support). The Cultural Adaptation Process model is a three-phase model (i.e., setting the stage, initial adaptation, adaptation iterations) in which researchers work closely with community stakeholders to examine fit of concepts, assess community-specific needs, pilot test adaptations, and make changes through pre-established feedback loops (Bernal et al., 2009). Resnicow et al. (1999) distinguish between surface structure adaptations (e.g translating materials from English to other languages, targeting recruitment in specific community spaces) and deep structure adaptations (e.g., integration of core cultural values, sensitivity to varied explanatory models) to interventions. Additional approaches to cultural adaptations include the distinction between top-down (i.e., applying universal content and concepts) and bottom-up (i.e., using culturally-specific knowledge of values, history, and customs of a particular subgroup) procedures (Barrera et al., 2013; Falicov, 2009).

Examples of Adapted EBTIs and Guidance on When Adaptations are Indicated

To address previously identified disparities, cultural adaptations to EBTIs have shown efficacy in the treatment of specific target problems/symptoms (e.g., depression: Ford-Paz et al., 2015; Nicolas et al., 2009; disruptive behavior disorders: McCabe & Yeh, 2009; McCabe et al., 2012; trauma: Flay et al., 2004; Goodkind et al., 2010). In addition to addressing specific community needs, cultural adaptations have also been employed to address implementation outcomes (e.g., acceptability, perceived appropriateness). For example, evidence of culturally adapted parent-child interaction therapy (PCIT) shows the adapted versions, which consider parent explanatory models of child behavior, are significantly more acceptable within the Latinx community than non-adapted versions of the intervention (McCabe et al., 2012).

Despite progress toward understanding how culture functions in the context of evidence-based care, definitive guidance on when cultural adaptations are indicated or needed is lacking. For example, a recent update of non-adapted EBTIs that have a strong evidence base with REM youth identified four “well-established” and ten “probably or possibly efficacious” interventions that draw mostly from cognitive behavioral and family systems models (Piña et al., 2019, p. 179). Further, in some cases cultural adaptations may unintentionally impede treatment progress. Huey et al. (2014) discuss that negative effects of culturally adapting interventions occur just as frequently as positive ones, and speculate that this could be a result of the removal of core mechanisms of behavior change or of negative reactions from clients who might prefer to receive the standard treatment. While the evidence remains mixed, one framework that may help determine when adaptation is needed is Lau’s (2006) proposed case for “selective” and “directed” cultural adaptations. First, empirical evidence suggesting poor fit between a target population and the intervention, which may indicate a lack of generalizability, would be used to select interventions to adapt judiciously. Then, data would also be used to direct the development and testing of the cultural adaptations that are made.

A recent review of meta-analyses found that while adapted interventions are efficacious when compared to traditional control groups, more research is needed to disentangle mixed findings (i.e., some adapted interventions reducing effectiveness) and moderator effects (e.g., tailoring to a specific cultural group, client age, acculturation) to determine when adaptations may be indicated (Huey et al., 2014). Best guidance from the current literature suggests that employing a data-driven approach is imperative to answering the question of when adaptations are needed. Further, iterative processes that involve community stakeholders in the development of the adaptations themselves could prove beneficial (Arora et al., 2021; Ramos & Chavira, 2022). These mixed findings suggest that a more flexible, idiographic approach to treatment development and implementation may be warranted and perhaps more impactful than adapted interventions that assume within-group homogeneity. Existing models for this alternative approach include Personal Relevance of Psychotherapy (PROP; Hall et al., 2021), a guide for reducing disparities by targeting the salience (i.e., “how meaningful and useful an intervention is,” “whether the treatment approach being used is seen as credible and matches clients’ belief systems and perceptions of what would be beneficial to them,” p. 2) of particular intervention elements according to universal, group, or individual differences. Incorporating biopsychosocial frameworks and precision medicine approaches, models like PROP allow for a personalized approach to treatment that acknowledges that patients exist in a unique cultural context.

Culturally-Adapted or Tailored TelePsychology/mHealth (TPmH)

Despite growing consensus that incorporating culture into psychotherapy is important, the rapid transition to TPmH due to the COVID-19 pandemic occurred with limited guidance around cultural responsiveness or integration. While the study of culturally responsive or adapted TPmH is still relatively new, findings from recent reviews and meta-analytic studies can help guide future research. A recent systematic review of 28 culturally adapted internet- and mobile-based interventions for mental disorders found that effect sizes for adapted studies (Hedges’ g ranged from g = 0.15 to 2.70) were comparable to the effect sizes of the corresponding un-adapted versions of the interventions (Spanhel et al., 2021). At the same time, completion rates for the culturally adapted interventions were low (50.6% of participants completed all sessions). Cultural adaptations to internet- and mobile-based interventions have included surface level modifications such as simplifying the navigation of mobile-delivered information and including interactive elements to enhance functionality. Deep level cultural adaptations included aligning treatment with a target groups’ explanatory models of mental health disorders and the use of culturally specific metaphors or sayings (Spanhel et al., 2021). Existing frameworks describing types of cultural adaptations may need to be expanded to include adaptations unique to TPmH (e.g., shortening text in apps, ensuring that design/aesthetic is culturally relevant, identifying the optimal level of human guidance). Importantly, Spanhel et al. (2021) also note that no study in their review included a direct comparison of the culturally adapted and un-adapted versions of the interventions. Further, there was significant heterogeneity in the types of interventions included in this review, including variability in intervention length (e.g., interventions ranged from 1 to 32 modules), duration (1 day to 8 months), and primary disorder (e.g., depression, anxiety, substance use, PTSD). Such heterogeneity precludes definitive conclusions regarding the influence of specific cultural adaptations on TPmH effectiveness.

Building upon this work, a meta-analysis of TPmH interventions designed to promote positive health behaviors (Balci et al., 2022) suggested that cultural adaptations may not be recommendable given their inability to outperform un-adapted versions of interventions in both short- and long-term settings. Importantly, both Spanhel et al. (2021) and Balci et al. (2022) focus primarily on adult samples, and to our knowledge no systematic review of culturally-responsive TPmH focused on youth exists. The current state of the literature suggests that while individual examples of effective, culturally responsive TPmH exist for youth (e.g., Abuwalla et al., 2019; Kanuri et al., 2019; Luo et al., 2021; Sobowale et al., 2013), our ability to discern when these adaptations are necessary to achieve optimal outcomes is limited and we cannot yet determine whether they outperform original, un-adapted interventions.

Given the limitations in existing culturally adapted TPmH, a recent review of TPmH for REM individuals highlights that culturally adapting TPmH, which is a time consuming and resource intensive process, may not be the most sustainable way to address existing barriers to TPmH (Ramos & Chavira, 2022). In lieu of culturally adapting TPmH, Ramos and Chavira (2022) recommend practices for research (e.g., reporting demographic information of study participants, testing if behavioral intervention technologies reduce barriers) and clinical practice (e.g., assessing comfort level with technology, considering cultural factors) that are intended to improve TPmH outcomes for REM participants. Such recommendations align with previously discussed models for integrating culture into psychotherapy through idiographic, flexible, personalized approaches (e.g., PROP; Hall et al., 2021) rather than through standardized cultural adaptations that may disregard within-group differences. In the spirit of this forward-thinking review, the following future directions are proposed to inform the next generation of culturally responsive TPmH research, practice, and policy. While we know that effective, culturally adapted TPmH interventions for youth exist, the following future directions will comment on the primary research gaps in this field including how best to integrate the cultural adaptation literature with literature studying the development of TPmH interventions.

Future Directions in TPmH Research, Practice, and Policy

The proposed future directions related to culturally responsive TPmH interventions critically examine current gaps in the research and identify research, practice, and policy priorities. We organize our recommendations into four cross-cutting themes: conceptual and theoretical recommendations, recommended research priorities, practice and policy recommendations, and engagement and access recommendations.

Conceptual and Theoretical Recommendations

Recommendation #1: Improve the Definitions of Telepsychology/mHealth (TPmH) to Facilitate Their Benefits for REM Youth and Their Families

There is significant variability in TPmH terminology and definitions, in part due to the ever-growing number of approaches, platforms, and devices used in the electronic provision of remote psychological services. Researchers use the terms “telepsychology,” “mHealth,” “telemental health,” “digital health interventions,” and “eHealth,” among others, in both distinct and overlapping ways (see Hollis et al., 2017 for a glossary of terms). For instance, mHealth may incorporate and/or exclude voice and/or video platforms (e.g., video conferencing), and may leverage a broad array of mobile technology (e.g., apps, text messages, interactive games) via a multitude of digital devices (e.g., smartphones, smartwatches, tablets). The lack of consensus regarding what constitutes TPmH and how the various terms listed above are distinct or overlapping is a significant barrier to the development of culturally-adapted TPmH for REM youth and families. Specifically, ambiguity in definitions challenges our ability to identify the specific types of TPmH that are most effective for these groups.

Discrepancies in definitions may have emerged for a variety of reasons, including variation across disciplines, the fast-paced evolution of technology, and research-implementation gaps. TPmH are used across a range of disciplines, including psychology, medical healthcare, social work, and computer science. Lack of integration across these fields may partially account for different standards of definitions and terminology, highlighting the need for cross-collaborative networks of TPmH researchers and practitioners. In addition, rapid changes in technology that outpace research may contribute to differences in terminology within and across fields over time. By the time that studies of TPmH are published and disseminated, additional technologies may be available, thus introducing confusion regarding how to update terminology to account for both older and newer forms of TPmH. Additionally, newer TPmH tools are introduced into practice more quickly than research can keep up, creating a research-implementation gap that might impact terminology. As new digital interfaces (e.g., virtual reality, augmented reality) and devices (e.g., affordable smart glasses and virtual reality headsets) emerge, the distinction and/or overlap among terms such as “telepsychology” and “mHealth” will continue to be blurred unless explicitly defined and consistently followed across disciplines and throughout research, policy, and practice.

To facilitate a shared understanding of TPmH, which in turn will improve research and practice surrounding TPmH for REM youth and their families, we strongly advocate for a clearer definition system. Deciding on clear and distinct definitions of telepsychology, mHealth, and related terms and consistently distinguishing among these terms will streamline the development and subsequent evaluation of these interventions. While clearer definitions will benefit all TPmH research, it has specific implications for REM youth and families. Various technological interventions, such as text-only versus video-conferencing, have different accessibility considerations and possibly different levels of effectiveness depending on the REM group utilizing them. As such, clear definitions will enable researchers to take into account culturally-specific barriers to access. For example, TPmH may be more accessible to REM youth residing in urban areas with affordable or free wireless internet than to REM youth in rural areas that lack such infrastructure. Nonetheless, socioeconomic factors in urban settings still may impact REM youths’ ability to engage with various TPmH modalities. For example, texting services may be more accessible as compared to services that rely on broadband connections or consistent, high-quality cellular coverage. Barriers like these ones have larger policy implications in that culturally-responsive TPmH rely on the ability for REM youth and families to have adequate access to the technologies and relevant resources (internet, electricity, etc.) to support the sustainability and expansion of these approaches.

Recommendation #2: Encourage Researchers to Report on TPmH Interventions in Greater Detail to Promote Scientific Growth

In addition to improving definitions of TPmH, researchers must also provide a greater level of detail when reporting on TPmH in publications and other dissemination materials. Improving reporting standards will increase transparency, thus allowing for a better understanding of the efficacy of TPmH for REM youth and families and identifying gaps for future research to fill. In particular, it is critical that researchers report the ways that cultural responsiveness has been incorporated into TPmH. A systematic review of culturally adapted interventions for youth (not specific to TPmH) found that only 50% of these studies specified the theoretical framework guiding their cultural adaptations (Arora et al., 2021). This limitation also extends to TPmH. When TPmH are culturally adapted, it is crucial that researchers clearly articulate their methods for doing so, including how technological aspects of their interventions have or have not been adapted to account for culture or barriers related to REM inequities. More detailed reporting of adaptations may help to clarify which adaptations are or are not helpful for REM youth and their families. Other aspects of TPmH besides cultural adaptations have also been underreported in the literature. For example, implementation of TPmH has ranged from including some form of therapist support through written messages, a combination of written messages and phone calls, face-to-face contact, or no therapist support or contact during the intervention at all (Vigerland et al., 2016), but these details are not always clear. Similarly, participant characteristics, such as severity of mental health symptoms, must be clearly reported. Providing such details can help the field determine which TPmH modalities or tools are most efficacious or warranted for which REM youth and their families (Gonzales et al., 2016). To facilitate improved reporting and contribute to shared knowledge, funding agencies and journal outlets should consider requiring that authors make their intervention protocols publically accessible (with respect to copyright considerations), and also describe in their methods how they specifically built or adapted TPmH in culturally-responsive ways.

Lack of detailed reporting on TPmH methodologies as well as ambiguous definitions of TPmH, as discussed in the previous recommendation, also affect “upstream” activities such as funding decisions and research priorities. Without a clear understanding of how prior research has defined or examined TPmH and how the field is defining TPmH moving forward, it may be challenging for institutions and funding agencies to reach consensus on what comprises a novel or impactful research project. For instance, funding calls for interventions that do not include the most effective components of TPmH for REM youth (e.g., text messaging, culturally-responsive digital resources, etc.) may continue to spur disparities in access to mental health services. A clearer understanding of (1) what constitutes TPmH and (2) how exactly TPmH has been applied in previous research will provide a necessary foundation for future research and can help identify critical gaps in the literature related to TPmH for REM youth and families. Ultimately, clear and consistent reporting and definitional systems of TPmH are a necessary starting point for ensuring that culturally-responsive TPmH interventions are developed, implemented, and prioritized.

Recommendation #3: Identify an Interdisciplinary, Cross-Cutting Theoretical Model to Guide Research on Culturally-Responsive TPmH

Although there are models for adapting in-person services to TPmH modalities (e.g., McCord et al., 2020) and for adapting EBTIs to be culturally-responsive (e.g., J. Chu & Leino, 2017; J. M. Jones, 2014), to our knowledge, there is no existing model that does both. The development of a dual adaptation model that provides guidance on how to tailor interventions to be both culturally responsive and appropriate for delivery via TPmH may advance research on culturally-responsive TPmH. Importantly, research suggests that it can be both feasible and effective to concurrently modify evidence-based interventions to be culturally-responsive for REM populations and to include TPmH components (e.g., Stewart et al., 2021). However, a model to guide these concurrent adaptations would be helpful, particularly given that some modifications may be unique to the intersection between cultural responsiveness and TPmH. Indeed, a recent review identified four types of adaptations unique to culturally-adapted TPmH (Spanhel et al., 2021), including modifications to an intervention’s structure (e.g., shortening modules), functionality (e.g., accounting for poor internet access), design and aesthetics (e.g., modifying graphics to be culturally relevant), and human guidance (e.g., considering how much human support is needed). Notably, these cultural adaptations to TPmH interventions are not comprehensively reflected in existing cultural adaptation frameworks, suggesting the need for a model that specifically targets culturally-responsive TPmH (Spanhel et al., 2021). Finally, any theoretical model focused on culturally adapted TPmH for REM youth should be developmentally sensitive and acknowledge the particular considerations of designing and implementing interventions for REM youth and families. These considerations include level of parent involvement, youths’ cognitive development, and the role of different systems on interventions (e.g.,, family, school, and community). Additional considerations that models should account for include the extent to which REM parents have access to their children’s data and how to balance protecting youths’ privacy while also engaging parents and other family members in therapy.

It is also imperative that a dual adaptation model provide guidance on how culturally specific risk and protective factors can be integrated into the development and implementation of TPmH. A large body of research has shown how these culturally specific factors (e.g., racial identity, racial socialization, etc.; Galán, Meza et al., 2022; Galán, Auguste et al., 2022; Galán et al., 2021; S. C. T Jones & Neblett, 2016) influence mental health for REM youth. This potential future model of TPmH adaptations and development should seek to bolster the specific evidence-based resilience factors, such as racial identity, religious beliefs, and racial socialization, which may be particularly important to REM youths’ psychosocial outcomes. In sum, we must strive to shift from “culturally-adapting” TPmH after it is developed, to making TPmH culturally-sensitive at the beginning. This involves theoretical frameworks that emphasize development, efficacy, and implementation efforts that are occurring concurrently in order to avoid the current lagging pipeline between the development, evaluation, and implementation of TPmH interventions.

It could also be argued that a dual adaptation model should not be focused on how to adapt interventions to be both culturally-responsive and digitally delivered but rather how to develop interventions from the ground up that are culturally-responsive and take full advantage of the technology at our disposal. Two existing fields of literature are broadly relevant in designing a dual adaptation model that addresses the latter question: implementation science and community-engaged research. Leveraging implementation science in the next generation of culturally-responsive TPmH interventions may provide a foundation for considering end-users in the design and sustainment of interventions in real-world settings. Integrating implementation science with cultural adaptation frameworks may help us address key questions such as when to initiate the cultural adaptation process, how to balance treatment fidelity with treatment acceptance, and how to enhance sustainability of EBTIs (Cabassa & Baumann, 2013). Community engaged research, a continuum of research practices and methodologies that prioritize involving community stakeholders (e.g., parents, community health workers, youth advisory boards) in activities such as the development of research questions and interpretation of findings (Wright et al., 2020), may serve as a tool that maximizes the sustainability of research efforts. Rather than developing culturally adapted interventions that may not be acceptable to community members who ultimately utilize the services, community-engaged research places an emphasis on developing sustainable solutions to community-identified problems in a collaborative and partnered process. The result of these efforts, particularly when applying implementation science frameworks that consider the local context of where interventions are implemented, will lead to interventions that are both flexible and culturally responsive. Examples of these efforts from in-person treatments include personalized models of Parent-Child Interaction Therapy that have resulted from ongoing community partnerships and take into consideration parent explanatory models for child behavior problems (McCabe et al., 2020). Additional frameworks include the aforementioned Personal Relevance of Psychotherapy (PROP; Hall et al., 2021), which allows for responsiveness to universal, group, or individual differences in treatment preferences by placing different levels of emphasis on treatment components that clients find relevant to their treatment and goals. By increasing our partnerships with end-users and a wide range of community stakeholders we can create interventions that are responsive and flexible to the wide range of REM youth and family needs without making sweeping adaptations that are applied in a one-size fits all manner. The result would be sustainable interventions that are acceptable to REM communities and responsive to their culture and identified needs.

Recommended Research Priorities

Recommendation #1: Empirically Evaluate the Effectiveness of TPmH Interventions for REM Children and Adolescents

Outcome research on TPmH interventions for REM youth is lacking, providing little information about the efficacy of existing services. Many existing studies have small sample sizes, no control group or non-rigorous control groups (e.g., treatment as usual). Limited engagement in mHealth interventions among youth also limit our ability to understand the efficacy of TPmH for this population (Cavazos-Rehg et al., 2020; Hightow-Weidman et al., 2021) Studies to date have also not consistently and thoroughly reported outcomes by racial-ethnic group, possibly because the samples often lack racial diversity. Those that include information on racial identity rarely explore outcomes by racial-ethnic groups. Additionally, most existing research has not examined constructs that are more pertinent to ensuring cultural-responsivity than a categorical race or ethnicity variable, such as racial identity beliefs, acculturative stress, and intersectionality beliefs and experiences. Despite major limitations in TPmH research for youth, many digital apps are publicly available for this age group. However, recent reviews of TPmh highlight that most publicly-available digital applications lack empirical support, evidence-based therapeutic components, and efficacy data across different REM groups (i.e., for an in-depth review, see Ramos & Chavira, 2022; for additional recommendations see Friis-Healy et al., 2021).

In light of these limitations, an urgent research priority is establishing how efficacious and effective existing TPmH interventions are for REM youth and their families. In order to achieve this goal, many approaches and considerations should be emphasized. First, future research should examine whether there are differences in outcomes for REM youth who engage with TPmH compared to in-person interventions. It will also be important to examine within-group diversity. This nuance will allow the field to determine if culturally-adapted TPmH interventions show differential effectiveness (both in terms of efficacy and engagement) for certain subgroups and intersections of REM youth (e.g., based on gender, sexual orientation, immigration status). This should also be extended to explore differential effectiveness for these populations in particular service areas (e.g., justice-involved youth, child welfare systems, school settings, outpatient hospitals, inpatient hospitals). Finally, it will also be important for research to test whether outcomes are improved with novel changes to TPmH services, such as enhancing the digital translation of psychotherapy to better mirror in-person services. Such research also should include exploring the therapeutic advantage of utilizing virtual platforms to create unique and culturally-relevant TPmH interventions, for example utilizing virtual reality, augmented reality, or extended reality in culturally-relevant ways.

Recommendation #2: Increase Research on Psychological Assessment Using TPmH

Although our earlier review focused specifically on culturally responsive TPmH interventions, culturally responsive psychological assessments delivered via TPmH should also be prioritized in future research. There is limited data on the feasibility of using TPmH to conduct psychological assessments in REM youth and families (Van Patten, 2021). TPmH may increase access to evidence-based assessments, yet it is not known if assessments have been digitally adapted effectively to be delivered virtually, especially among REM populations (Bilder et al., 2020). We must also take into account that “evidence-based” assessments may not be culturally relevant or accurate when administered to REM youth (Byrd & Rivera-Mindt, 2022), which again raises the question of if assessments should be “adapted” for REM youth or developed from the ground-up to be culturally-responsive.

There are many ways in which technology may improve our assessment approaches, especially among REM youth. TPmH for psychological assessments can take advantage of cutting-edge technologies and softwares to increase the accuracy of assessments used with REM youth. For example, utilizing machine learning approaches that are trained and tested on culturally-representative data and constructs could produce more accurate symptom profiles for REM youth. Such approaches could also help to combat existing biases within machine learning algorithms (e.g., misclassification, underestimation, etc.) among larger healthcare and research institutions to improve service delivery to REM youth (Gianfrancesco et al., 2018; Volpe et al., 2021). Machine learning approaches could also be used to build “decision support tools” that have the potential to help mental health providers make better decisions about when and how to use culturally-responsive TPmH versus in-person interventions (Park et al., 2022). Furthermore, wearable technologies such as smartwatches, fitness bands, and smart glasses could help improve assessment of symptoms for REM youth, by recording, in-real time, physiological responses to race-related stressors, as well as other sociocultural factors. Researchers could also use these technologies to administer “daily diary” questionnaires related to REM youth’s mental health and other experiences. In conclusion, psychological assessments administered via TPmH may be particularly promising for REM youth and their families given their ability to use novel methodologies and technologies to overcome biases and help us better understand sociocultural factors and their influence on mental health symptoms.

Practice and Policy Recommendations

Recommendation #1: Develop Evidence-Informed Guidance on How to Integrate a Variety of Culturally-Responsive Technological Approaches for Intervention

As previously discussed, “TPmH” is an umbrella term that encompasses a variety of technological approaches to mental health treatment. The ambiguity in TPmH terminology not only presents conceptual challenges, but also limits researchers’ creativity and thoughtfulness regarding how to leverage and integrate the multitude of possible technological modalities to deliver mental health services to REM youth. In the next wave of culturally-responsive TPmH development, the field should strive to develop practice guidelines on how to best integrate a variety of TPmH modalities. In other words, we must think creatively about how to combine the use of technology such as apps, text, video, voice, and other multimedia interfaces to bolster treatment accessibility, engagement, and efficacy among REM youth and their families.

For instance, through the use of push notifications, apps have the ability to help parents of REM youth manage appointments and remain engaged in therapy, either in-person or via video or phone. This may improve upon previous research that shows that text-based appointment reminders may serve to overcome existing disparities in attrition and dropout (Fernandez et al., 2011). Similarly, on-demand access to digital resources such as culturally-adapted worksheets and psychoeducational materials could be made available separately to parents and youth through their own dedicated app access and profiles. This approach may support mental health literacy and engagement among REM parents in their child’s treatment, while protecting the privacy of how REM youth are engaging with TPmH. Furthermore, interventions could leverage the integration of augmented and virtual reality in mobile devices to also deliver exposure-based interventions via live video telehealth sessions with virtually-created stimuli. For example, interventions that use these technologies could potentially simulate feared stimuli such as spiders in one’s real-life environment via augmented reality, or could transport clients into virtual speaking engagements during sessions via virtual reality. Technologies such as virtual and augmented reality could help not only improve engagement in EBTIs, but could offer novel, effective ways of delivering psychoeducation and other therapeutic interventions, which is a burgeoning area of research among scholars of color (Cogburn et al., 2018; Tynes & Willis, in press). Wearable technologies could also be leveraged to deliver psychoeducation, daily monitoring of symptoms, intervention strategies, and to as well improve engagement with treatment (e.g., via homework, appointments, and medication reminders). In sum, it is critical that researchers identify best practices for integrating multiple technologies for REM youth.

Recommendation #2: Prioritize the Sustainability of Evidence-Based, Culturally-Responsive TPmH Interventions

In addition to a lack of research on the effectiveness of culturally-adapted TPmH, we also know very little about how these interventions can be sustained for REM youth. Unlike in-person interventions, TPmH may involve digital infrastructures that may be more challenging to maintain over time, especially in underresourced settings. Therefore, the development of best practices for sustaining culturally-adapted TPmH interventions should be prioritized.

To accomplish long-term sustainability, there must be clear guidelines outlining who is responsible for ensuring that TPmH applications are technologically sustained based on the latest software and hardware. Creating and maintaining sustainable systems likely requires that there is support for cross-disciplinary teams consisting of mental health stakeholders, TPmH developers and researchers, and REM community members. As technologies advance, established TPmH interventions must be continually updated to ensure not only that they operate efficiently on newer devices, but also that platforms are protected against any security weaknesses or hackers, and are up-to-date with evolving ethical standards. These precautions will promote continued engagement with culturally-adapted TPmH among REM youth and ensure that trust in these platforms are not undermined by breaches of privacy data. Relatedly, to facilitate sustained trust in and use of evidence-based TPmH by REM youth and their families, the field urgently needs to develop systems for regulating both nonprofit and for-profit existing TPmH interventions on the market (Mohr et al., 2021). Many TPmH interventions exist on the market that are for-profit, not created alongside mental health professionals, and/or not rooted in evidence-based principles (Ramos & Chavira, 2022). Regulating TPmH interventions will ensure that those that are on the market and targeted toward REM youth are evidence-based, increasing trust and engagement among REM populations. Finally, for those TPmH that may require users to purchase software, or pay a subscription fee, sustainability will only be accomplished if we can ensure that insurance companies nationwide will cover and/or reimburse for these services. In the end, there may be many other factors to consider when ensuring sustainability of culturally-adapted TPmH, so relevant stakeholders should consider this an “iterative process” and be open to adjusting these practices to best suit the needs of REM populations.

Recommendation #3: Provide Training and Support in Culturally Responsive TPmH for Trainees in Health Service Psychology

Current approaches to clinical training have failed to prepare trainees with the knowledge, self-awareness, and skills to work with communities of color (Galán et al., 2021). Although Health Service Psychology programs are making efforts to improve training in cultural humility, to our knowledge, most of these trainings have centered on cultural humility when delivering in-person services. Although TPmH are now widely used, training for clinicians in these modalities is lacking (Hames et al., 2020; Saenz et al., 2019). As programs continue to provide students with the opportunity to deliver telehealth services, it is critical that we prioritize training students in how to deliver such services with cultural humility. In an effort to ensure that evidence-based, culturally responsive TPmH are disseminated widely, clinical training programs must prepare the next generation for utilizing these interventions. In other words, there must be mandated practice guidelines that ensure that trainees in Health Service Psychology (e.g., clinical psychology, social work) receive adequate training in delivering culturally responsive TPmH. First, research should identify concerns held by the mental health workforce about delivering psychosocial interventions via TPmH and identify strategies for supporting providers. Graduate programs should also provide training in interdisciplinary research methods and collaboration, such as how to work alongside application developers, user experience analysts, and marketing professionals. Such training will help to improve the design of evidence-based TPmH interventions and reduce implementation timelines. Providing high-quality training in delivering culturally responsive TPmH also relies on research identifying and improving on the effectiveness of culturally responsive TPmH as previously discussed.

In addition to training, programs must also provide concrete technological resources to students so that they can effectively deliver culturally responsive or adapted TPmH. One of the first challenges students may face, especially students from under resourced backgrounds, is access to working devices and effective internet. Lack of access to reliable hardware and internet may disproportionately impact graduate students who are from low-income backgrounds and/or already feeling financially strained by their graduate student stipend (Palitsky et al., 2022; Walsh et al., 2021). Faculty members and supervisors may assume that students have access to a camera-enabled mobile device and high-speed internet due to their status as graduate students, but delivering psychotherapy via TPmH devices often requires additional resources. For instance, even if one has the necessary “hardware” (i.e., a computer with a working camera and microphone), there can sometimes be difficulties with devices being able to effectively handle the various programs required for telehealth (i.e., Zoom, Microsoft Teams, etc.), as well as the cost associated with high-speed or broadband internet. Access to broadband internet is often a challenge for students who are not wealthy, who do not live alone, or who may have others utilizing the same internet or WiFi (Swanson et al., 2021). These barriers can be distressing to student therapists as they lead to disconnections or visual/audio difficulties that impact their ability to deliver services effectively. Moreover, student therapists may not have the resources to create an environment that is conducive to delivering treatment. For instance, students who are parents, live with family members or roommates, and/or who have limited space within their homes are at a particular disadvantage (Palitsky et al., 2022). Given these challenges, it is important that training programs implement policies that ensure trainees are provided with additional resources that allow them to effectively conduct TPmH sessions, such as funding for mobile-devices or computers and reimbursement for high-speed internet services.

Health Service Psychology training programs should also acknowledge that, although TPmH are increasingly popular, it remains unclear if they are the best treatment modality for all clients (Galán et al., in press). As such, although many Health Service Psychology trainees may prefer TPmH due to the flexibility it affords to work remotely (Palitsky et al., 2022), trainees and supervisors should thoughtfully consider for which clients and under what circumstances TPmH are or are not preferred to face-to-face services (Galán et al., in press). As discussed in earlier sections, it is not yet known whether TPmH introduce new barriers to mental health services, particularly for REM youth and their families. Thus, training programs should be hesitant to create blanket policies that encourage all services to be provided via TPmH. Rather, consistent with personalized models of culturally responsive psychotherapy (Hall et al., 2021), programs should consider individual and cultural client factors to justify the use of TPmH versus face-to-face modalities.

Engagement and Access Recommendations

Recommendation #1: Improve Engagement and Community Involvement in TPmH Development and Implementation Among REM Youth

Despite the utility of TPmH for treating psychological symptoms, limited engagement by REM youth in TPmH research and clinical services challenges our ability to design, evaluate, and implement culturally-responsive TPmH for REM youth. REM youth remain underrepresented in TPmH research, despite their high ownership of smartphones (Smith & Page, 2015), and their common use of smartphones to access the Internet (i.e., Zickuhr & Smith, 2012). Evidence also shows that engagement in TPmH interventions among youth, including REM youth, may be limited (Cavazos-Rehg et al., 2020; Hightow-Weidman et al., 2021), which further undermines our ability to understand the efficacy of TPmH for this population. For example, in one study, although over 80% of youth were interested in trying TPmH apps, nearly two-thirds indicated that they would not be willing to obtain parental consent to participate in research due to privacy concerns and perceived lack of social support from parents related to mental health (Cavazos-Rehg et al., 2020). Lack of engagement by REM youth in TPmH research limits our understanding of how TPmH interventions should be developed and designed for this group to effectively target disparities in access to and utilization of mental healthcare. Thus, research should identify which engagement strategies for TPmH work best for REM youth and their families, and the field should develop best practices for engaging these communities in the development and implementation process for TPmH.

To improve engagement and ensure that TPmH interventions are meeting the needs of REM youth, we propose that intervention development should take a “client-centered” process that uses collaborative research approaches (e.g., focus groups, user experience testing of interventions). There is a particular need for taking a patient-centered approach to TPmH development in youth, who have different perspectives on and relationships with technology than adults. For example, Silva et al. (2021) proposes a method that blends motivational interviewing techniques and culturally-sensitive assessment to enhance TPmH engagement among Latinx populations. It may also be helpful to draw from community-engaged research frameworks (Israel et al., 2001; Wright et al., 2020), which allow community members to play an equal role in the research process and to integrate the voices of the community in the process of ensuring that interventions are culturally responsive. Community engaged research methods and related strategies have not yet been widely adopted in the context of TPmH, but burgeoning research highlights that REM youth can play a vital role in the development and creation of culturally-relevant implementation strategies for TPmH (Willis & Neblett, 2021). It will be important for TPmH research to consider how cultural responsiveness or cultural adaptations affect intervention reach and engagement, as this relationship has not been studied as systematically as the effect of cultural adaptations on intervention efficacy.

In addition to adapting the process of TPmH research, it is also important for researchers to consider logistical factors that may affect the extent to which REM families engage in TPmH. Providing access to devices during research studies for REM youth, in addition to compensation, can help improve engagement and community involvement in the development of TPmH by REM youth and their families (Truong et al., 2022). Utilizing creative marketing strategies specific to REM youth and families is a critical part of engagement and utilization (Willis & Neblett, 2021). Far gone is the “if we make it, they will come” mentality of psychological science, and if we are to reduce barriers and increase access to TPmH among REM youth and their families, we must go through culturally relevant avenues. Utilizing culturally relevant recruitment strategies also requires increased funding for this type of outreach from institutions and foundations. Additionally, in order to prioritize the recruitment of REM youth and their families into TPmH research and treatment, researchers must acknowledge that the onus is on them, and not on REM communities, to reduce the barriers that have resulted in inequities in TPmH utilization among REM communities. Another important consideration related to the implementation of TPmH is addressing privacy concerns, as REM youth and families are wary of how their private health information will be used given longstanding experiences of misuse by health systems (i.e., Jennings et al., 2016). Considering how factors like privacy concerns interfere with both research and treatment engagement, and how researchers and practitioners can overcome these barriers, will greatly improve the ability to study and implement culturally-responsive TPmH. TPmH should explicitly state, in systematic, culturally-responsive, and developmentally appropriate ways how, why, and when protected health information will be used. For example, participants should be aware of which entities have access to their information, how this information will be used and protected, what information will be shared with family members, and whether diagnoses reflect cultural norms. This transparency not only increases trust between REM populations and the technologies they use for mental health services, but it also increases the likelihood that these communities will engage with TPmH interventions, and begins to chip away at the warranted mistrust that REM populations have for healthcare systems. Rebuilding this trust may mean increasing the standards of transparency beyond researchers to also include software developers, marketing experts, funding agencies, and others. Given recent abuses of protected health data in which TPmH services have sold data to for-profit agencies (Levine, 2022), it also may be important to develop more robust systems for preventing such data breaches to reduce the likelihood that these online interventions further health disparities (Volpe et al., 2021).

Finally, burgeoning research that explores mHealth attitudes among REM youth also indicate that African American youth perceive a lack of social support and understanding from older family members around mental health treatments and help-seeking support (Willis & Neblett, 2021). In light of these findings, it is urgent that future research also provide psychoeducation to REM parents to further increase the likelihood that REM youth participate in TPmH research studies, giving us the ability to obtain data on the efficacy of these interventions for this population.

Recommendation #2: Policies Should Address How to Best Disseminate TPmH Services Among REM Youth in Light of Existing Disparities

Research should identify how the shift to TPmH has affected access to mental health services for REM youth and their families. TPmH interventions are not a “silver bullet” in terms of resolving disparities in access to or utilization of mental health services. Although TPmH may improve access to mental health services for some REM youth and their families, digital inequities, such as lack of digital literacy, access to technology, and high-speed internet, may introduce new barriers to engaging with services for others (Cheshmehzangi et al., 2022; Friis-Healy et al., 2021; Pew Research Center, 2022). Indeed, approximately 11 million youth in the U.S. live in homes without internet and/or computers, which likely limits access to TPmH (Smith-East & Starks, 2021). Further, some youth may lack access to a safe, private, and secure location to participate in therapy, an issue that has been compounded by changes related to COVID-19, such as parents working full-time from home and children attending school virtually from home (Lee & Parolin, 2021; Zamarro & Prados, 2021). Unsurprisingly, finding these spaces is even more challenging for REM youth from low-income backgrounds and/or those who live in small spaces (e.g., in urban areas). Traditional systemic barriers to mental health treatment also may remain present despite TPmH. In fact, these obstacles may impact TPmH in more complex ways. For example, access to childcare is often a barrier to treatment engagement among marginalized groups. Although TPmH allows families to engage in treatment from home, lack of access to childcare during telehealth sessions can impact parents’ ability to engage in therapy, especially when there is only one caregiver in the home with multiple children. Similarly, preexisting disparities in access to resources and other determinants of health outcomes (e.g., food, housing, employment, adequate insurance) have been exacerbated by the COVID-19 pandemic, and disproportionately affected REM families (Dooley et al., 2020; Thomeer et al., 2022). These stressors impact the psychological well-being of clients from these backgrounds, and are undoubtedly more stressful or debilitating during this crisis, and may limit ability to access and engage with any mental health services, including TPmH.

If research suggests that TPmH have increased disparities in access to mental health services among certain REM populations, then it will be important for researchers to elucidate key factors contributing to such inequities. Alternatively, if the adoption of TPmH has decreased disparities, then it will be just as important to understand and better characterize why and how these modalities are improving access to mental health services for REM youth. Based on future research findings related to the impact of TPmH on access to mental health services, policies should be developed to address how to best disseminate TPmH services among REM youth in ways that reduce inequities. For instance, resulting policy changes may consider the importance of prioritizing TPmH as a means of service over in-person services, especially in differing outlets (outpatient settings, inpatient settings, private practice, schools, etc.). For example, there may be differences in insurance reimbursement for TPmH versus in-person services among these settings, and these disparities in which services are “reimbursable” will also differ depending on state and federal regulations, further exacerbating access to TPmH. Also, policies that support practical interventions for increasing digital literacy, as well as provide funding for increasing access to digital devices and internet among REM families will also be crucial. Overall, healthcare systems and training programs should take on the responsibility of making effective TPmH services more accessible for these populations.

Conclusion

Advances in technology (e.g., increased access to smart devices and broadband internet) have provided clinical scientists and mental health providers with unique tools and formats through which to deliver mental health services to children and families. TPmH offers promise in our efforts to reach youth and families who are in need of services. For REM youth and families who often experience inequitable access to effective mental health services, TPmH offer a chance to overcome these disparities with interventions designed to fit with family and community values. Existing literature on cultural adaptations to EBTIs offers a number of possible frameworks to make interventions more relevant and aligned with REM values. However, limitations in the time it takes to generate adaptations and demonstrate their effectiveness may not be worth their treatment gains when compared head-to-head with un-adapted versions of the same interventions. The future directions outlined above offer suggestions on how to consider the lessons learned from cultural adaptations to EBTIs in a way that addresses the urgency of resolving disparities in access to services. We propose ten directions that consider the complexities of developing sustainable technology-assisted interventions while striving for culturally-responsive care. It is clear that our efforts will require consistent reflection on the language we use to describe our research and interventions, ongoing community partnerships and engagement, and increased training and support for trainees and clinicians delivering services using TPmH. To support REM youth and families, we must take these directions into consideration and continue fighting for mental health equity free of disparities.