Background
Parenting management training (PMT) has been shown to be effective in the treatment of children with ADHD and other externalizing disorders [
1,
2]. Moreover, it has been found that behavioral PMT significantly reduces child denial behavior and noncompliance as well as parental stress [
3]. Behavioral PMT aims to teach positive parenting skills in order to reduce common externalizing problems associated with ADHD symptoms in children. Generally speaking, behavioral PMT is based on cognitive behavioral strategies such as learning how to give effective commands and implementing contingency management strategies [
4]. In view of the established evidence for the efficacy of (conventional) PMT, it forms part of the recommendations in current guidelines for ADHD, along with cognitive behavioral therapy and pharmacotherapy [
5‐
7]. However, due to treatment supply gaps, which have been further compounded and magnified by the COVID-19 pandemic, there is an urgent need for evidence-based, low-cost, innovative, and easily accessible treatment approaches [
8,
9].
Research has shown that innovative forms of treatment such as web- or telephone-based parental interventions can overcome some of the structural and social barriers (e.g. parental work commitments, fear of judgment) to accessing and attending parent management interventions in the treatment of child externalizing behavior problems [
10,
11]. Indeed, several systematic reviews have reported that web-based PMTs are effective in reducing problem behavior, mostly with small to moderate effect sizes [
12‐
16]. Furthermore, there is sufficient evidence that regular use and attendance is an essential prerequisite for the efficacy of any treatment, including web-based interventions [
17].
In an online survey, some parents of school-aged children expressed a preference for parenting information on child mental health to be delivered via online programs rather than face-to-face training [
18]. For a face-to-face PMT program, Breitenstein and coworkers found uptake rates (at least one session) of 76%, with mean attendance rates of 50% (out of 12 sessions) [
19]. In later research, the same authors reported significantly higher module completion rates (85.4%) for an adapted tablet-based parent management program compared to attendance of sessions in face-to-face training [
13]. In a randomized controlled trial comparing face-to-face and online behavioral parent training, DuPaul and colleagues found moderate acceptability for online PMT as rated by parents [
20].
To date, however, operationalizations of the concept of acceptance of computerized interventions are heterogeneous, and measures of acceptance and utilization range from direct measures (e.g., self-report) [
21] to objective measures (e.g., uptake time), with internet technologies enabling user behavior in digital health interventions to be measured and tracked. Addressing the inconsistent designation and definition of the term acceptance, Rost and colleagues concluded that “it is not an instantaneous act”, but instead a process of “accepting, experiencing, and being satisfied.” [
22]. Prior to the advent of objective data tracking, empirical studies used subjective ratings by users, meaning that previous research often lacks validity, potentially resulting in over- or under-reporting of the acceptance and utilization of interventions. Nevertheless, such measures are often used to complement objective data [
23]. Objective measures of utilization focus on temporal aspects (e.g., frequency, duration) and depth dimensions (e.g., amount use of specific intervention content in percentage terms) [
21,
24]. However, such a one-dimensional description has been criticized given that, for example, users may be logged in for a long period of time while making little progress. Therefore, researchers have called for a multidimensional description in terms of the so-called FITT categories (i.e., frequency, intensity, time, and type of engagement), which provide concrete dimensions associated with behavior-changing aspects of an intervention. The type of engagement can in turn be distinguished into “active” use (e.g., self-monitoring, writing) or “passive” use (e.g., viewing the intervention without interacting) [
25].
A recent study by Tarver et al. (2021) identified several factors that may act as barriers to the utilization of web-based PMT, such as the presence of siblings during the intervention [
26]. Unfortunately, most research findings do not allow for reliable inferences regarding the direct influence of individual variables (e.g., socioeconomic status) on the utilization of web-based interventions [
16]. A meta-analysis revealed that older age, higher educational attainment, and female gender of the user were relevant factors influencing engagement with digital behavior change interventions (DBCIs) in adults [
21]. DuPaul and colleagues recommend focusing on possible predictors in order to provide the optimal care tailored to the needs of individual families, as their research demonstrated similar effects of face-to-face and online PMT in terms of acceptability and engagement [
20]. However, in addition to sociodemographic and socioeconomic factors that may affect the utilization of web-based interventions, telephone-based support by therapists has been found to improve adherence and motivation [
26]. Indeed, our own investigations showed that low-frequency telephone-based support by specialists can even improve the outcome effects of an intervention [
27]. With the ultimate aim of improving the therapeutic supply situation for families with children with ADHD, the present study seeks to enhance the understanding of which families are likely to utilize web-assisted self-help.
Therefore, we investigated the acceptance and utilization of a so-called web-assisted self-help parent management training (WASH) program as part of the routine care of ADHD and other externalizing problems such as oppositional defiant disorder (ODD). A detailed and objective assessment of the parameters of utilization should provide more reliable insight into acceptance and utilization compared to previous studies that investigated self-reported usage or one-dimensional objective parameters [
28]. Participants were randomized into two intervention groups (with and without additional telephone-assisted support) and compared regarding their acceptance and utilization of the online parent management training. We expected participants receiving additional telephone support to accept and use the intervention more often and intensively. In line with the literature and previous research on acceptance, we expected good overall acceptance regarding the WASH intervention. Based on previous findings and discussions, we took a multidimensional perspective to describe and analyze caregivers’ utilization of the intervention, and expected to find, for example, that socioeconomic status, single parenthood, the option of personal telephone-assisted support, and the degree of parental psychopathological problems would be associated with and predictors of acceptance and utilization of WASH for parents.
Discussion
To the best of our knowledge, the present study is the first to systematically investigate and describe factors of parental acceptance and utilization in the context of web-assisted self-help interventions for parents of children with ADHD. Our results demonstrate that (1) acceptance of WASH is high, both according to objectively collected data and self-report, and (2) the additional support calls as well as child- and caregiver-related psychopathology and positive parenting are the main predictors of acceptance and utilization. Unfortunately, like previous research, we were not able to include the underserviced target group of caregivers in less served regions, with less educational background and families with less access to evidence based ADHD treatment. Our sample has a rather high socioeconomic status, which should be considered in the following discussion and especially regarding the generalizability of the results.
Our data reveal that WASH is well accepted for both active intervention groups (with and without telephone support), as documented both by objective measures (uptake rate and return rate: from 70 to 85%) and subjective measures (self-report: 90–95%). The uptake rate was comparable to the rate of 76.4% (i.e., attending at least one session) reported in the Chicago Parent Program, a face-to-face parent training program for families from low-income urban communities [
19]. Our results fit well with other web-based treatments, such as the ezParent program to prevent child behavior problems in preschoolers, in which only a third of the participants who signed up, from a low-income population, failed to attend any sessions [
13]. In fact, in the present study, only 15% of participants did not log in to the WASH program at all, indicating that acceptance in our sample was higher than that in the ezParent program. These good acceptance rates may be attributable to the advantages of online interventions: WASH is available 24/7 and can be easily accessed through a smartphone, tablet, or laptop and from anywhere with internet access. Previous analyses have likewise indicated a preference for online treatment for caregivers of children with anxiety and depression [
18]. Flexibility in parent training, as a key element of acceptance, was also reported by Tarver and colleagues in qualitative analyses of an ADHD self-help program [
54]. It has to be taken into account, that the ezParent program is an intervention addressing families of cultural diversity and with particular needs. Therefore, comparisons of the results should be interpreted with caution. Regarding the initial login (uptake), using CART, we were able to correctly predict acceptance for about 74% of cases, which is considered acceptable [
50]. The prediction of the return rate showed an even better performance, with 84% correct predictions. It has been expected that online interventions such as WASH may primarily be accessed by those in less well-served supply situations such as rural areas. However, our results did not support this assumption: For both initial uptake and return, ADHD/ODD symptoms of the child, caregiver psychopathology (depression, anxiety, and stress), and parenting style were important predictors. The most important predictor of return was the number of support calls, with a higher number of calls increasing the probability of return, in line with earlier research findings [
22]. For a small group of caregivers, a very high level of self-reported positive parenting predicted non-acceptance in terms of no initial uptake. This predictor was also found in the decision paths for the return rates, indicating that caregivers with high levels of positive parenting (combined regarding return rate with less than two support calls and higher levels of ADHD) might not expect the program to be helpful for them. Moreover, even when they do accept the intervention, they tend to use it less in terms of frequency and intensity (cf. Figs.
5 and
6), supporting the hypothesis that the intervention is not very promising in this population.
Overall, research on acceptance has yielded divergent findings to date, which might be explained by the very different operationalizations of the term acceptance itself. Indeed, many research groups interpret it more in the sense of satisfaction with an intervention, rendering it difficult to compare the research findings on (online) PMT acceptance. For instance, a recent study examining behavioral parent training (BPT) with additional child-therapist support reported high acceptance based on caregivers’ satisfaction (e.g. “The length of the treatment program met my expectations and the needs of my family”), which caregivers self-rated with mean scores between 3.8 and 4.9 on a five-point Likert scale [
55]. Generally speaking, there does not yet appear to be any agreed-upon best practice when it comes to evaluating patient/ user acceptance in the context of internet-/mobile-based health interventions [
56]. Future research should assess acceptance based on theoretical models such as the well-established
Unified Theory of Acceptance and Use of Technology [
57], which is often reported as both theory-based and as empirically proven for the evaluation of acceptance (in technology) and focuses on aspects such as attitudes towards the technology, self-efficacy (health- and technology-related), and perceived barriers (such as security barriers).
Regarding the utilization of WASH, an average frequency of five logins (out of six recommended sessions) was found, which can be described as an 83.3% attendance rate. A study analyzing a comparable training program for parents of children with ADHD, provided either face-to-face or online, reported a mean of 80% session attendance/ completion, which the authors described as “high”, and a t-test indicated no significant group differences between the online and the face-to-face condition [
20]. On the other hand, the utilization in terms of completed tasks/videos in the present study is rather low (average of 31.7%). However, participants of WASH were free to choose how they engaged with the program (in terms of logins and which tasks/videos they completed) and a 100% completion rate was not expected due to the modular architecture of the website, allowing parents to only use the tasks/videos they perceived as relevant to them. A systematic review on the use of technology and digital delivery methods of parent management training reported a content completion rate ranging from 41.7 to 99.2% [
58].
The decision tree models for utilization of WASH were able to correctly predict for 80% how often (number of logins) and how intensively (number of completed tasks/videos) the intervention was used. In these analyses, telephone-based support was the most important predictive variable for both utilization parameters. The influence of the number of support calls is more relevant than simply the offer of support (in one intervention group), as this variable had the same likelihood of becoming a predictor in the CART models but was not included. These findings are in line with previous research in smaller samples [
26]. With comparably little support (at least two support calls), the frequency of use increased significantly, whereas more intensive support (six support calls) led to an improvement in intensity of use. However, when discussing the relevance of this variable, it is necessary to consider further variables found in the decision paths. As the efficacy of a treatment depends on its actual use, and the mere attendance of an intervention does not ensure positive intervention outcomes [
17,
59], additional therapeutic support is necessary to enhance utilization. Moreover, the results provide initial indications that a differentiated consideration of different utilization parameters certainly appears to be useful. Some variables are related to both parameters, as a higher age of the user of an online intervention was found to be associated with more frequent and more intensive utilization, thus confirming previous research findings of a meta-analysis on different interventions [
21]. This seems surprising, and contradicts previous findings on caregivers’ engagement in an internet-based health intervention (addressing a child’s asthma), in which younger caregivers were found to log in more often [
60].
Some variables, however, were exclusively relevant for either frequency or intensity of use: The presence of siblings in the same household is one factor that may prevent caregivers from using web-based interventions [
54]. Using CART, we were able to show that the number of persons per household did affect caregivers’ frequency of use (but not the intensity). It is important to note that expected factors such as being in a partnership/ married, and in line with previous research [
26], availability of afternoon childcare, were predictively associated with more frequent logins, indicating that the intervention may have been more easily accessible for these families. Exclusively (for the group of caregivers aged below 47 years), educational attainment was found to predict the intensity of use, insofar as caregivers with an especially high educational status used the intervention more.
Limitations
In terms of the findings mentioned above, it is important to note that the socioeconomic status of our sample was rather high, and the distribution of social parameters was skewed. In line with a previous study examining the role of parental engagement in a parenting program aimed at reducing risk factors of child depression and anxiety [
61], we reached a mainly female, middle-aged, educationally highly qualified sample. This will primarily be an effect of the referral context (clinical utilization sample assigned by practicing psychiatrists or pediatricians), with the attractiveness of WASH for a selective sample only being a secondary factor in this regard.
The WASH study was able to make an important contribution to the empirical evaluation of factors of acceptability and utilization of web-assisted self-help. A strength of this analysis is the automatic data tracking, which enabled objective information on the acceptance and usage of the website. However, the tracking of utilization did not allow for any statements about the order of usage. Future studies should thus endeavor to record the utilization of modules in chronological order, in order not only to explain the general effectiveness but also to specify which contents of cognitive behavioral web-assisted self-help in ADHD parent management training are effective. Furthermore, we cannot guarantee that users actually engaged with the content rather than merely “clicking through” the intervention, as we did not conduct knowledge quizzes to prove caregivers’ engagement.
Using the method of CART analysis, we were certainly able to follow an inductive approach and consider diverse predictive variables for the utilization of WASH and how they are related to each other, instead of investigating pre-selected predictors. A visual comparison of the two decision trees (frequency and intensity of use) reveals differences that might hint at multiple ideas for optimizing the intervention, but should not be over-interpreted due to the limited power of the sample.
In conclusion, it seems advisable to include different parameters, as there are clear differences between objective and subjective measurements, indicating that an under- or overestimation of acceptance (and potentially utilization as well) occurs when approaches exclusively use subjective measures. Moreover, we were not able to include information on why caregivers did not use the intervention due to missing data; causes of non-acceptance and factors of drop-out should be considered in future research. Further research is needed to assess the efficacy of specific content and individual modules of the intervention and to further illuminate the important role of the support calls, especially regarding the intensity or frequency of support. The decision tree findings provide a useful contribution to the discussion of whether, and for whom, web-assisted self-help interventions can be helpful. Our results clearly underline the need for targeted recommendations oriented to specific criteria (e.g., with the help of decision tree findings), and highlight that support from a specialist who provides individual guidance throughout the intervention (main predictor) is especially important when attending web-based training, and renders the actual utilization of the intervention more likely.
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