Mobile Health Solutions for Behavioral Skill Implementation Through Homework

The aim of the proposed study is to develop a theory-informed mobile health (mHealth)
application for urban caregivers attempting to improve their children's oppositional and
conduct related difficulties (i.e., disruptive behavior disorders; DBDs). The majority of
evidence-based treatments (EBTs) targeting youth DBDs emphasize change in specific
parenting/family-level processes empirically linked to the maintenance of DBDs. Existing
EBTs frequently include at-home-practice-exercises (i.e., homework; HW) to reinforce parent
skill acquisition and maximize use of new skills with children at home. Poor quantity and
quality of HW completed by parents significantly attenuates the effect of EBTs. This is a
significant limiting-factor in many EBTs attaining full public health impact. Given the
robust effect of HW on outcomes from EBTs across a range of behavioral health difficulties
and populations, there is a call for moving beyond the question of whether HW is important
to questions such as what processes are involved in HW implementation and how best to
support these processes. Minimal investigation has been focused on these critical questions.

A model of HW has recently been proposed to better understand the process of HW
implementation, as well as guide critically needed supports for at-home practice exercises.

This model proposes four HW processes:

1. Designing;

2. Assigning;

3. Doing, and;

4. Reviewing.

The DADR model proposes that specific social, cognitive and behavioral factors related to
the HW task, as well as to the provider and the adult caregiver may affect the quality of
each phase and ultimately to the quantity and quality of HW completed. Methods to better
understand, support, and impact these processes are essential to advancing theory and
offering solutions to HW completion.

Through features available on smartphones (e.g., camera/video/voice recording; simple
message service; internet-access; global positioning system), there are novel methods to
interface with and support clients outside of defined treatment sessions. Through the use of
these features, mHealth applications can be used to engage, educate, connect, track, and
remind clients. These applications can use push (send communications) or pull (client's
access tools on their own) mechanisms to engage the client in behavioral change activity.
mHealth applications that integrate push and pull methods offer a significant opportunity to
enhance outcomes across a range of health and behavioral health challenges and populations.

The goal of this two-year R34 treatment development grant is in response to RFA-MH-13-061
(Harnessing advanced health technologies to drive mental health improvement) to develop a
mHealth application that will both advance theory in and clinical practice guided by the
DADR model of HW implementation. Specifically we aim to utilize mHealth to improve the
"Design" and "Do" process of HW within the context of the Family Groups for Youth with
Behavioral Difficulties (MFG) intervention, an EBT for DBDs in youth and their families who
seek assistance at outpatient mental health clinics in urban communities. To date, efforts
at utilizing mHealth within the context of HW have been minimal and have not taken a
systematic, theory-driven approach, thereby limiting the advance of knowledge and clinical
application. Through utilizing self-determination theory as a guiding framework and
integrating principles from the field of "gamification" and goal-setting, the aim is to
develop a two-component MFG mHealth HW application (My MFG). The first component focuses on
delivering MFG HW via a highly engaging, multiplayer, interactive, cooperative, and
skill-building game platform aimed at improving the "Design" and "Do" process. The second
component focuses on targeting factors putatively related to poor HW implementation within
the "Do" process.

The process of the development of My MFG will be guided by the clinic and community
development model and iterative software development process to maximize the feasibility and
sustainability of My MFG within practice settings often characterized by limited resources.
The specific aims of this project are to:

1. Develop My MFG through an iterative process informed by the perspectives of key
stakeholders

2. Determine the impact of MFG plus My MFG relative to MFG-alone on the DADR process and
HW quantity and quality. It is hypothesized that the MFG plus My MFG will result in:

1. Greater quality of the "Design" and "Do" process rated by therapists, parents, and
independent coders

2. Greater quantity and quality of HW assignments rated by therapists and parents

3. Greater quality of the "Review" process as rated by therapists, parents, and
independent coders as a function of improved HW quantity and quality

4. Greater satisfaction with treatment as rated by the parent, target child, and
therapists NIMH has specifically called for acceleration of research to maximize
the ability of current treatments to reduce symptoms, improve adherence and
functioning while improving quality of and lowering the cost of care. The mHealth
application and methods proposed herein serve as systematic, theory-driven
approaches to significantly advance understanding of how best to support the HW
process—a common element of many EBTs across various disorders and
populations—ultimately resulting in greater effectiveness of EBTs, maintenance and
generalization of behavioral skills learned during EBTs.

Inclusion Criteria:

1) youth between the ages of 7 to 13 years and an accompanying adult primary caregiver
available to participate in the research and intervention activities 2) English speaking
youth and adult caregiver and 3) youth meeting criteria for DBD via parent reports based
on the Disruptive Behavior Disorder (DBD) rating scales of DSM symptoms and
cross-situational impairment as assessed through parent ratings on the Impairment Rating
Scale (IRS). Children will be diagnosed with DBD if they meet DSM symptom criteria for DBD
by parent report (i.e., at least four symptoms of ODD or 3 symptoms of CD), and impairment
ratings indicate at least one impairment domain.

Exclusion Criteria:

Children will also be excluded if there is:

- Evidence of psychosis

- If the youth or adult caregiver presents with emergency psychiatric needs that
require services beyond that which can be managed within an outpatient setting (e.g.
hospitalization, specialized placement outside the home), active intervention by
clinic and research staff to secure what is needed will be made

- Children will not be excluded if they participate in other psychosocial or
pharmacological interventions.