A Review of the Key Considerations in Mental Health Services Research: A Focus on Low-Income Children and Families

Factors influencing technology use among low-income older adults: A systematic review

As the world's aging population increases, leveraging technology to support aging is proving advantageous. Notably, technology adoption studies among older adults have received increasing scholarly attention, but findings from these studies do not reflect the context of low-income older adults. Studies focusing on low-income older adults were relatively few and it remains unclear which factors influence this group's technology use. This systematic review aims to synthesize findings on factors influencing technology use among low-income older adults to provide directions and opportunities for future research in information systems. Observing the literature through the lens of Social Cognitive Theory, we identified avenues for future research and further integrated the framework with Maslow's hierarchy of needs to elucidate the phenomenon. Findings from this systematic review suggest that both personal and environmental factors, such as cognitions, affects, sociodemographic characteristics, technological and social environment are significant predictors of technology use among low-income older adults. Specifically, factors related to accessibility and affordability, such as income, perceived cost, and accessibility to technology are salient in a resource-limited setting. More importantly, the technology usage behavior elucidate the embeddedness of fundamental human needs which plays a central role underlying technology use among this segment. However, more research is needed to understand the interaction between person, environment and behavior determinant shaping technology use among low-income older adults from diverse economic and cultural setting. This study also sheds light on disciplinary gaps and the lack of investigations anchored on theoretical foundations, and suggests avenues for future research and implications for practice.

The Socioeconomic Indicators Linked to Parent Health-Related Technology Use: Cross-sectional Survey

Background

Despite the prevalence of parent health information seeking on the internet and its impact on parenting behavior, there is a paucity of research on parents of young children (ages 3 to 8 years). Given the importance of this developmental period, exploring how family socioeconomic indicators linked to the digital divide and health inequities affect parent proxy- and self-seeking is critical to further understanding variability in health information seeking and associated outcomes.

Objective

This study aimed to explore parental health-related technology use (HTU), the process by which parents engage in support, advice, and information-seeking behavior related to their (self-seeking) and their children’s (proxy seeking) health across a range of hardware devices (eg, tablet, wearable, smartphone, laptop, and desktop computer) and sources (eg, search engines, mobile applications, social media, and other digital media).

Methods

A cross-sectional study including 313 parents and guardians of children ages 3 to 8 years recruited through Amazon Mechanical Turk (MTurk) was conducted. Parents were asked to complete a self-administered questionnaire on a broad range of parenting and parent-related constructs, including sociodemographic information, technology device ownership, and engagement in and use, features, and perceptions of HTU. Descriptive and bivariate analyses (chi-square tests) were performed to identify patterns and investigate associations between family socioeconomic indicators and parent HTU.

Results

The overwhelming majority (301/313, 96%) of parents of young children reported engaging in HTU, of which 99% (300/301) reported using search engines (eg, Google), followed by social media (62%, 188/301), other forms of digital media (eg, podcasts; 145/301, 48%), and mobile applications (114/301, 38%). Parents who engaged in HTU reported seeking information about their child’s behavior and discipline practices (260/313, 83%), mental or physical health (181/313, 58%), and academic performance (142/313, 45%). Additionally, nearly half (134/313, 43%) of parents reported searching for advice on managing their stress. Among parents who reported using each source, an overwhelming majority (280/300, 93%) indicated that search engines were a helpful online source for proxy- and self-seeking, followed by social media (89%, 167/188), other digital media (120/145, 83%), and mobile apps (87/114, 76%). Among parents who reported using any technology source, approximately one-fifth reported that technology sources were most comfortable (61/311, 20%), most understanding (69/311, 22%), and most influential toward behavior change (73/312, 23%) compared to traditional sources of health information–seeking, including mental health professionals, other health care professionals, school professionals, community leaders, friends, and family members. Indicators of family socioeconomic status were differentially associated with frequency and perceptions of and search content associated with parent HTU across technology sources.

Conclusions

The findings of this study underscore critical considerations in the design and dissemination of digital resources, programs, and interventions targeting parent and child health, especially for families in traditionally underserved communities.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Regulating digital therapeutics for mental health: Opportunities, challenges, and the essential role of psychologists

With so many promising digital therapeutics for anxiety and obsessive-compulsive (OC) spectrum problems, there is an urgent need to consider how evolving regulatory oversight of digital therapeutics is poised to shift how these tools are developed, evaluated, reimbursed, and delivered. In this commentary, we discuss both opportunities and potential pitfalls associated with emerging government regulations of digital therapeutics for mental health, and we consider how applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine and limit the broad accessibility of these software-based innovations that have been explicitly designed to expand the accessibility of care. For example, the vast majority of behavioural and mental health providers do not have 'prescription privileges' (a term originally rooted in pharmacologic practices), and as a result, under current regulations in the U.S. would not be authorized to make FDA-cleared digital therapeutics available to their patients. This is particularly concerning given that most digital therapeutics for mental health are directly rooted in psychological and behavioural science, yet psychologists would not be authorized to incorporate these innovations into their practice. We consider how synchronizing regulatory standards across countries may prove useful, and we conclude by arguing that multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the discipline and practice of psychology. PRACTITIONER POINTS: Emerging government regulations of digital therapeutics for mental health present both opportunities and potential pitfalls Applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine the broad accessibility of these software-based innovations. Synchronizing regulatory standards across countries may prove useful. Multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the field of psychology.

Optimizing Engagement in Behavioral Parent Training: Progress Toward a Technology-Enhanced Treatment Model

Low-income families are more likely to have a child with an early-onset Behavior Disorder (BD); yet, socioeconomic strain challenges engagement in Behavioral Parent Training (BPT). This study follows a promising pilot to further examine the potential to cost-effectively improve low-income families' engagement in and the efficiency of BPT. Low-income families were randomized to (a) Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003), a weekly, mastery-based BPT program that includes both the parent and child or (b) Technology-Enhanced HNC (TE-HNC), which includes all of the standard HNC components plus a parent mobile application and therapist web portal that provide between-session monitoring, modeling, and coaching of parent skill use with the goal of improved engagement in the context of financial strain. Relative to HNC, TE-HNC families had greater homework compliance and mid-week call participation. TE-HNC completers also required fewer weeks to achieve skill mastery and, in turn, to complete treatment than those in HNC without compromising parent satisfaction with treatment; yet, session attendance and completion were not different between groups. Future directions and clinical implications are discussed.

Where Did All the Sport Go? Negative Impact of COVID-19 Lockdown on Life-Spheres and Mental Health of Spanish Young Athletes

During the 2020, the pandemic caused by the massive spread of the SARS-CoV-2 coronavirus (COVID-19) resulted in a global crisis. In Spain, the COVID-19 pandemic caused a lockdown for almost 100 days and forced the sudden stop of sport practices and competitions. This interruption had a negative impact on high-level athletes’ mental health. However, its impact on young athletes, who are intrinsically developing a high-demanding dual career, remains unclear. Therefore, this study aimed at (1) describing and characterizing the general impact that COVID-19 lockdown had on Spanish young athletes’ life-spheres and mental health, and (2) identifying different profiles of athletes regarding life-conditions and sport-related variables. A sample of 544 young athletes (M = 15.9; SD = 1.51) participated in this study. Measures included life-conditions and sport-related information along with the Holistic Monitoring Questionnaire (HMQ) and the General Health Questionnaire (GHQ-12). After the screening and description of the data, profiles were defined using a two-level cluster analysis using HMQ and GHQ-12 subscales. We explored differences in demographic and sports information between profiles using MANOVA and subsequent ANOVA. Results suggest a general negative impact of COVID-19 on young athletes’ life-spheres and mental health, but with three different clusters regarding the degree of such impact. Cluster 1 grouped the 54.78% of the sample and exhibited a low negative impact of COVID-19 lockdown on life-spheres and few mental health issues. Cluster 2 grouped a 29.96% of the participants who reported a medium negative impact on life-spheres and moderate mental health issues. Cluster 3 represented 15.26% of the sample including participants who showed a high negative impact of the COVID-19 lockdown with high mental health issues. The paradigmatic participant in this third group would be a female student-athlete from a medium or low socioeconomic status with high academic demands and poor or inexistent training conditions during lockdown. Current findings emphasize the need to pay attention to young athletes’ mental health and suggest possible influencing contextual variables. We suggest some applied recommendations aimed at helping clubs and sports institutions to mitigate the negative effects of such difficult circumstances on athletes’ mental health.

Social Emotional Learning Program Boosts Early Social and Behavioral Skills in Low-Income Urban Children

Social emotional learning (SEL) programs are increasingly being implemented in elementary schools to facilitate development of social competencies, decision-making skills, empathy, and emotion regulation and, in effect, prevent poor outcomes such as school failure, conduct problems, and eventual substance abuse. SEL programs are designed to foster these abilities in children with a wide range of behavioral, social, and learning needs in the classroom, including children who are economically disadvantaged. In a previous study of kindergartners residing in a high-poverty community (N = 327 at baseline), we observed significant behavioral improvements in children receiving an SEL program-The PATHS® curriculum (PATHS)-relative to an active control condition within one school year. The present investigation sought to determine whether these improvements were sustained over the course of two school years with intervention and an additional year when intervention was no longer provided. Further, using multilevel models, we examined whether baseline measures of neurocognition and stress physiology-known to be adversely impacted by poverty-moderated heterogeneous outcomes. Finally, a preliminary linear regression analysis explored whether neurocognition and physiological stress reactivity (heart rate variability, HRV) predict change in outcomes postintervention. Results confirmed that students who received PATHS sustained significant behavioral improvements over time. These effects occurred for the full sample, irrespective of putative baseline moderators, suggesting that children in high-risk environments may benefit from SEL interventions irrespective of baseline cognitive functioning as a function of overall substantial need. Of interest is that our exploratory analysis of change from waves three to four after the intervention concluded brought to light possible moderation by baseline physiology. Should subsequent studies confirm this finding, one plausible explanation may be that, when an intervention providing protective effects is withdrawn, children with higher HRV may not be able to regulate physiological stress responses to environmental challenges, leading to an uptick in maladaptive behaviors. In reverse, children with lower HRV-generally associated with poorer emotion regulation-may incur relatively greater gains in behavioral improvement due to lesser sensitivity to the environment, enabling them to continue to accrue benefits. Results are discussed in the context of possible pathways that may be relevant to understanding the special needs of children reared in very low-income, high-stress neighborhoods.

Helping the Noncompliant Child: An Updated Assessment of Program Costs and Cost-Effectiveness

Behavior disorders (BD) in children can lead to delinquency, antisocial behavior, and mental disorders in adulthood. Evidence-based behavioral parent training (BPT) programs have been developed to treat early-onset BDs, yet cost analyses of BPT are deficient. We provide updated estimates of cost and cost-effectiveness of Helping the Noncompliant Child (HNC), a mastery-based BPT, delivered to low-income families. The cost of research-specific activities was $1,152 per family. HNC program delivery costs were $293 per family from a payer perspective, including the cost of therapist time ($275 per family) and non-labor resources, such as supplies and toys ($18 per family). It costs an average of $6 to improve the Eyberg Child Behavior Inventory intensity score by each additional point or $171 to improve it by one standard deviation. The cost of delivering the HNC program appears to compare favorably with the costs of similar BPT programs.

Cumulative socioeconomic status risk and observations of parent depression: Are there associations with child outcomes?

Parental depression (Goodman et al., 2011) and low socioeconomic status (SES) are important risk factors for child maladjustment. Further, depression and low SES are linked; low SES adults are more likely to experience depression. Whereas studies commonly covary out noise associated with SES variability, research on the association of SES with child outcomes after controlling for parental depression is limited. This study aimed to extend the literature by observing parent depressive affect and evaluating the relationship between cumulative SES risk and child problems as well as whether child gender moderates this association using multigroup nested model comparisons. Findings suggested that cumulative SES risk status explained significant variance in child- and parent-reported internalizing problems and parent-reported externalizing problems after accounting for observed parent depressive affect. Of importance, child gender moderated 2 of these significant findings (i.e., child-reported internalizing and parent-reported externalizing behaviors), such that girls, but not boys, were at higher risk of problems in the context of high cumulative SES risk. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Influence of Race and Income on Community Mothers' Acceptance of Child Management Methods

The consideration of diverse family factors on parents' acceptance of behavioral parent training (BPT) components aids in the development and delivery of culturally sensitive parenting programs. Perceptions of acceptability are particularly important to investigate among low-income and racial-minority families, as they are less likely to engage in nonadapted BPT programs. Therefore, the current study examines the synergistic effects of race and income on mothers' acceptance of five common child management methods relevant to BPT. The relationship between mothers' acceptability ratings and self-reported parenting practices was also explored. Participants were 106 White and Black mothers from different income levels who completed measures related to the acceptability of response cost, positive reinforcement, time-out, spanking, and medication. The results indicated that mothers from varying backgrounds differed in their acceptance of child management methods, particularly with regard to corporal punishment. Additionally, a relationship was found between parents' acceptability ratings and their self-reported parenting behavior. The findings support the consideration of parents' perceptions of child discipline methods when recommending and delivering BPT programs to diverse parents.

Parent-Adolescent Socialization of Social Class in Low-Income White Families: Theory, Research, and Future Directions

The formative role of social class in the United States has long been a focus of fields such as economics, history, and political science. Yet, little psychological theory or data are available to guide our understanding of what messages regarding social class are transmitted within and across generations and how those transmissions are most likely to occur. As a launching point for such work, we focus this initial contextual and largely theoretical review on parent-adolescent socialization of social class in low-income, White families of adolescents in particular. To this end, our goal was to raise potential hypotheses about the implicit and explicit ways that White low-income parents may shape adolescent views of class, as well as the meaning and implications of status socialization for adolescent health and well-being.

Cost Effectiveness of Strategies for Recruiting Low-Income Families for Behavioral Parent Training

The goal of this study was to assess cost, effectiveness, and cost-effectiveness of recruitment strategies used to engage low-income families of young children with disruptive behavior disorder to participate in a Behavioral Parent Training (BPT) program. For this analysis, we used data on labor and non-labor resources associated with 13 recruitment strategies implemented in February 2014 through February 2016. We assessed the effectiveness of each strategy as the number of families that enrolled into the study. Cost-effectiveness of each recruitment strategy was expressed as cost per family enrolled; analysis was conducted in 2016. We calculated the cost of total recruitment effort for 13 strategies during the 2-year period to be $11,496 with an average cost of $885 per recruitment strategy or $255 per enrolled family. Across strategies, total costs ranged from $25 to $2,540. "University mass e-mail" and "school flyers" resulted in the most phone screens (34 each); however, only 10% of these families enrolled in the study (3 and 4 families, respectively). "Craigslist" was the most effective strategy with 30 families screened and 11 of them enrolling. Three strategies did not yield any participants. The four strategies with the lowest cost per family enrolled were "Facebook page," "Craigslist," "university mass e-mail," and "organization/agency" (< $90). In conclusion, we found that some recruitment strategies were more successful at engaging low-income families to participate in a BPT program than others. Our results indicate that using a combination of recruitment strategies may be the optimal approach for recruiting low-income families.

Young Children with Behavior Disorders in Low-Income Families: The Role of Clinic Observations in the Assessment of Parenting

Children from low-income families are at elevated risk of meeting diagnostic criteria for behavior disorders. Although mastery-based Behavioral Parent Training (BPT) programs have a robust evidence-base for reducing disruptive behaviors of young children, socioeconomically disadvantaged families are more likely to drop out of treatment and, in turn, are less likely to benefit. Therefore, efficient assessment and treatment may be needed. Less research, however, has addressed the value of time-consuming behavioral observations relative to caregiver-report of problem behaviors in the assessment of this at-risk and underserved group. In the current study, 43 low-income parents and their clinic-referred child were observed during a standard mastery-based BPT interaction task (Child's Game) at baseline. Findings revealed that parents were observed to displayed an extremely high proportion of maladaptive behaviors targeted for reduction by subsequent treatment (Instructions plus Questions) relative to behaviors that the treatment was designed to increase (Attends plus Rewards). In contrast, parents reported they utilized relatively high and low rates of positive and negative parenting, respectively. Behaviorally-observed parenting was not correlated with caregiver-reported parenting. The findings suggest that baseline observations of behaviors targeted in mastery-based BPT interventions are an important part of assessment in parenting programs for low-income families with young disruptive children.