What do we know about services administered virtually?
The preferences and experiences of children and families — as well as evidence about what works to improve outcomes — should be central to the provision of any supports and services, and those delivered virtually are no different. Families may appreciate the convenience and comfort of virtual engagement, but some providers have been reluctant to offer virtual interventions due to concerns about equitable access to the internet and whether online interventions can be as effective as in person.
The COVID-19 pandemic created an immediate need for the virtual administration of services, dramatically heightening interest and demand. That catalyzed the use of several virtual programs already developed, and led to quick pivots to effectively deliver other services virtually. The collective experiences of these programs,1 coupled with emerging research, offer important insight about the benefits and considerations that should be made when planning for virtual engagement. Recognizing the challenges child welfare agencies face providing Title IV-E prevention services to families in the midst of the pandemic, the Administration on Children, Youth and Families is allowing programs and services to be adapted for virtual administration.
The current landscape
Numerous online interventions for children and families have been developed. Some, such as the 5-a-Day Parenting Program and Parents as Teachers at USC (University of Southern California) Telehealth, are completely online. Others, such as the e-Parenting Program and SafeCare ®, are offered in person with augmented content provided digitally. Virtual interventions also range from “light touch” programs (such as Text4baby, which provides health and safety information to pregnant women and mothers of infants) to more intensive one-on-one programs (such as home visiting and psychotherapy).
Potential benefits
Research studies have begun to examine the feasibility and efficacy of delivering interventions to children and families virtually, and a growing number of online interventions have demonstrated effectiveness. A small study of online delivery of Group Triple P Positive Parenting Program found that treatment effect sizes were similar to those for programs offered in person.2 A randomized controlled trial found that offering Triple P Online resulted in improved outcomes for problem child behavior, parent confidence, parent anger, and dysfunctional parenting.3 In Australia, MindSpot offers online assessment and treatment for anxiety and depression, with demonstrated improvements in symptom severity.
Existing research4 and the experiences of providers suggest delivering interventions virtually can address longstanding issues that have traditionally limited their reach. Technology offers the potential for widespread screening and clinical assessment, which can be used to identify families for whom targeted prevention and/or intervention programs should be offered.5 Virtual home visiting and other family strengthening or clinical interventions offer the potential for increased scalability and access, and may significantly impact child maltreatment rates. Virtual methods offer the following potential benefits:
- Increased engagement: Some agencies that use Family Group Decision Making (FGDM) and other types of family meetings report that more family members are attending meetings online than regularly would in person and that people who may not speak up in person express themselves using online chat features. In addition, people who are less likely to attend interventions in person because of perceived stigma may be more willing to attend an intervention online. Self-directed interventions may also increase engagement, permitting parents the flexibility to access information and activities at a time that is convenient for them, and revisit modules they need or want more time with.
- Reduced logistical barriers: Offering interventions virtually can help clients in dense, urban areas, where traffic makes travel inefficient, as well as in rural and frontier areas, where long distances make in-person meetings challenging. Inclement weather and illness are also less likely to disrupt services when done virtually.
- Increased cost-effectiveness: Given that providers do not need to spend time driving to and from clients’ houses (for home visiting, for example), agencies benefit from reduced mileage costs and freed-up staff time. Further, providers report that they appreciate not needing to travel.
- Increased efficiency: Online interventions can reach a higher number of people at a lower cost than in-person interventions, potentially improving the reach of evidence-based programs. The Computerized Intervention Authoring System, for example, allows researchers and developers to deliver screenings, assessments, and interventions online.
- Increased provider availability: When providers do not need to be physically present with clients, a great deal of flexibility is gained in matching providers with clients. Providers offering Parents as Teachers online through USC Telehealth can work across state lines and across time zones. This increases providers’ ability to accommodate families’ scheduling constraints. In addition, providing interventions online addresses the shortage of providers in remote areas.
- Better monitoring of engagement and fidelity: Online interventions can track usage metrics automatically, allowing providers to monitor the program in real time. Fidelity monitoring can also be built into online interventions to ensure they are being delivered as designed. Lyssn, a secure platform for conducting and recording online psychotherapy sessions, automatically transcribes conversations and creates metrics that provide feedback to counselors and supervisors. Lyssn offers automatic fidelity assessments of Trauma-Focused Cognitive Behavioral Therapy and Motivational Interviewing. “There are real advantages in terms of increasing fidelity,” says Steven Ondersma, professor and deputy director of the Merrill Palmer Skillman Institute for Child & Family Development at Wayne State University in Detroit. “We’ve struggled as a field to provide a lot of behavioral/psychological/mental health services with fidelity. If providers are all under one roof, they can serve the whole country and develop institutional expertise.”
Coaching parent-child interactions virtually can be more fruitful than when you’re doing it in person. Often when you’re in a person’s living room, they default to you leading, and that’s the last thing we want in home visitation. We want the parents to lead. When there’s a video screen or phone between us, all you can do is coach them with your words and ask them to explain to you what they’re seeing, feeling, and thinking. That’s really powerful.
– Dorian Traube, Associate Professor, University of Southern California Suzanne Dworak‑Peck School of Social Work
Key considerations
Although the benefits of offering virtual interventions are numerous, there are some challenges that must be addressed to authentically engage children and families. The following considerations may be helpful when developing and adapting interventions for online administration.
Be family-driven
To ensure that families are meaningfully engaged in online interventions, it is important to check in with them regularly about what is and is not working, and what they may need to move forward. When adapting an intervention to online, it is helpful to solicit input from parents. Some home visiting providers have decreased the length and increased the frequency of home visits delivered virtually. One provider noted that when families expressed their preference for a particular web-based platform, the provider was able to research and implement it. When possible, it can also be helpful to provide families options for communication with clients, such as video calls, phone calls, or text messages.
For Lucy McGoron, assistant professor at the Merrill Palmer Skillman Institute at Wayne State University, involving families in the development of the Parenting Young Children Checkup was a priority from the beginning. “We’ve spent a lot of time doing qualitative interviews with parents, showing them materials, seeing how they react to them, getting their ideas, seeing how to change them,” she says. “That’s a really time-intensive process, but I think it’s really important to get their buy-in so they will be willing to engage in the program.”
Family Group Decision Making (Kempe Center at the University of Colorado)
The Kempe Center at the University of Colorado responded to the COVID-19 pandemic by creating an online COVID-19 Resource Center, which includes an information sheet for virtual engagement. The Kempe Center has also hosted regular “virtual world café” talks with topics informed by attendee input, such as preparing adults to participate in FGDM and other types of family meetings virtually, preparing and including children, and navigating family conflicts online. FGDM providers report benefits of offering family meetings online: families can meet in individual breakout rooms, providers and families can use polling questions, and people can type plans in real time that everyone can see.
Facilitate access to technology
Although most U.S. households have broadband internet access at home, lower-income households are significantly less likely to have access. For a list of resources to help youth and families access technology, see How can youth and families involved with child welfare access needed technology?
Ensure families are comfortable
Families may need support with technology so they are set up for successful engagement. For example, in preparation for a virtual FGDM meeting, it could be helpful to schedule a practice session with family members. For virtual home visiting, it may be useful to help families set up their camera so that the provider can see interactions between the parent and child.
Listening to families’ experiences is the most important thing we can do,” emphasizes Lisa Merkel-Holguin, associate professor of pediatrics and director of the National Center on Family Group Decision Making at the Kempe Center. “Increasingly, agencies organizing virtual family meetings are conducting short surveys and quality checks, seeking families’ ideas and getting a quick assessment of their experience: did this work for you, did it not, why or why not, and what can we do more of?”
Support providers in learning technology
The COVID-19 pandemic resulted in a steep learning curve for both families and providers, many of whom may not have previous experience with web-based platforms such as those used for videoconferencing. Providers that offer virtual interventions should be provided the time to familiarize themselves with a platform’s capabilities and restrictions. SafeCare® Colorado, implemented with the support of the Kempe Center intermediary, began meeting with supervisors weekly instead of monthly to provide a place of connection and allow for discussions of practice adaptations, and offered a weekly virtual “coffee hour” for providers. Other providers, including some offering online FGDM, have formed small groups in which they practice using the various components of their web-based platform. Practitioners should make sure their faces are visible and that lighting and sound are good.
The Rapid Response-Virtual Home Visiting collaborative, funded by Heising-Simons Foundation, is developing and disseminating free training and technical support opportunities during the COVID-19 pandemic. The collaborative is committed to ensuring that all home visiting professionals have what they need to support families virtually. The collaborative has created a series of webinars on topics such as different types of technology, enrollment, screening, engaging families using a protective factors approach, supporting families’ mental health, reflective supervision, self-care, and program sustainability.
In response to the COVID-19 pandemic, Incredible Years has been offering its evidence-based parenting classes online. In Colorado, MotherWise recently offered its first Spanish-speaking Incredible Years class online. Incredible Years created a thorough list of resources for group leaders working remotely, including a tipsheet for reaching out to families and parent evaluation forms specific to virtual administration.
Security and platform capabilities
Families, providers, and leaders have expressed concerns about the security of online platforms, given the potential for confidential information to be exposed. Providers should use best practices to ensure platforms are secure (for example, requiring a password) and HIPAA compliant.
Providers may not be familiar with the functionality and limitations of hosting sessions on web-based platforms, such as assigning people to virtual breakout rooms, using chat features, and displaying documents online. Since it can be more difficult to see physical cues from participants when they are online, it is important to use other methods, such as verbally checking in or using an online chat option.
Adapt curriculum as needed
Since meeting online is inherently different from meeting in person, it is important to ensure that interventions delivered online maintain fidelity to the in-person intervention (if an in-person option exists). Program developers can work with providers and families to determine how to translate curricula for virtual implementation.
The USC Telehealth program has been offering Parents as Teachers home visiting virtually since 2015. Parents as Teachers at USC Telehealth provides parents with individual conversations with home visitors (using interactive video technology), developmental and health screenings, opportunities to meet other parents online, and access to resources. USC worked with the Parents as Teachers National Center to adapt the in-person curriculum for digital delivery. Families and providers have provided positive feedback, and evaluation results show that the online program is delivered with fidelity.6 During the program’s first four years, 2,000 virtual home visits took place. Between March and July 2020, in the midst of the COVID-19 pandemic, over 150,000 virtual home visits were conducted.
Plan for recruitment
Recruitment for virtual interventions can be a challenge. Just because an effective intervention is available doesn’t mean people will use it. Programs need to develop recruitment strategies to proactively connect parents with the program (child care centers, for example). Given the large number of families that visit pediatricians, pediatric practices are one potentially effective place to recruit. In Detroit, parents visiting pediatricians’ offices are invited to participate in the Parenting Young Children Checkup. In the waiting room, parents fill out a questionnaire. Based on their responses, they can sign up to receive text messages that link to videos demonstrating parenting skills that are common in evidence-based parenting programs. Recruitment for the program has shifted due to the pandemic and is now being conducted through Brilliant Detroit. This intervention is an example of an online prevention program that can reach a broad population.
1 Based on interviews with Katherine Casillas, Director of SafeCare® Colorado, and Assistant Professor at the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado Anschutz Medical Campus, and Jamie Preuss, SafeCare® Colorado Site Manager and Trainer at the Kempe Center, July 16, 2020; Anita Horner, Manager at the National Center on Family Group Decision Making at the Kempe Center, June 24, 2020; Lucy McGoron, Assistant Professor at the Merrill Palmer Skillman Institute, Wayne State University, July 7, 2020; Lisa Merkel-Holguin, Associate Professor, Pediatrics, at the Kempe Center and Director of the National Center on Family Group Decision Making, June 16, 2020; Steven Ondersma, Professor in the Departments of Psychiatry & Behavioral Neurosciences and Obstetrics & Gynecology at Wayne State University, and Deputy Director of the Merrill Palmer Skillman Institute, June 29, 2020; and Dorian Traube, Associate Professor of Social Work, University of Southern California Suzanne Dworak-Peck School of Social Work, July 22, 2020.
2 Reese, R. J., Slone, N. C., Soares, N., & Sprang, R. (2015). Using telepsychology to provide a group parenting program: A preliminary evaluation of effectiveness. Psychological Services, 12(3), 274–282. https://doi.org/10.1037/ser0000018
3 Sanders, M. R., Baker, S., & Turner, K. M. (2012). A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems. Behaviour Research and Therapy, 50(11), 675-684. https://doi.org/10.1016/j.brat.2012.07.004
4 Hall, C. & Bierman, K. (2015). Technology-assisted interventions for parents of young children: emerging practices, current research, and future directions. Early Childhood Research Quarterly, 33, 21-32. https://doi.org/10.1016/j.ecresq.2015.05.003
5 Self-Brown, S. & Whitaker, D. (2008). Parent-focused maltreatment prevention: improving assessment, intervention, and dissemination with technology. Child Maltreatment, 13(4), 400-416. https://doi.org/10.1177/1077559508320059
6 Traube, D. E., Hsiao, H., Rau, A., et al. (2020). Advancing home based parenting programs through the use of telehealth technology. Journal of Child and Family Studies, 29, 44–53 (2020). https://doi.org/10.1007/s10826-019-01458-w