Tantrum Tool: Development and Open Pilot Study of Online Parent Training for Irritability and Disruptive Behavior

Abstract

Objectives:

Parent management training is an effective treatment for disruptive behavior disorders but it is often underutilized in clinical settings. Access to care is limited due to logistical barriers as well as limited service availability. This study examines in an open trial the acceptability, feasibility, and clinical effects of a digital parent management training intervention that includes videoconference coaching, called “Tantrum Tool.”

Methods:

Fifteen children, ages 3–9 years, participated in an open trial of an 8-week intervention. The primary symptom measure was the Disruptive Behavior Rating Scale (DBRS), and the secondary outcome measure was the Affective Reactivity Index (ARI) completed by the primary caregiver before and after treatment.

Results:

Treatment retention was high (80%), and parents reported a high level of satisfaction with the program. There was a significant reduction in the mean DBRS score from 13.5 ± 5.5 at baseline to 7.3 ± 3.4 at endpoint, p < 0.001. There was also a significant reduction in the mean ARI irritability score from 7.2 ± 2.6 at baseline to 3.75 ± 2.1 at endpoint, p < 0.01.

Conclusions:

This open pilot study supports the feasibility and acceptability of a digital parent training program for young children with disruptive behavior. Findings provide preliminary support for a clinically meaningful reduction of both disruptive behavior and irritability. Using the Tantrum Tool to deliver online treatment for children could increase access to first-line treatments for disruptive behavior and irritability in young children. ClinicalTrials.gov: NCT03697837.

Introduction

Disruptive behaviors are among the most common reasons for mental health referral in children and among the most costly childhood conditions (Cohen and Piquero 2008; Soni 2015; Johnston and Burke 2020). An estimated 5.7% children have a diagnosable disruptive behavior disorder (DBD) (Polanczyk et al. 2015). One-third to one-half of children with DBDs also meet criteria for attention-deficit/hyperactivity disorder (ADHD), and comorbidity typically worsens the prognosis (Waschbusch et al. 2002; Larson et al. 2011). Untreated oppositional defiant disorder (ODD) predicts anxiety, depression, and/or conduct disorder later in life (Burke et al. 2010).

Another disorder that presents with temper tantrums that can escalate to aggression is disruptive mood dysregulation disorder (DMDD). For children with DMDD, outcomes are also quite grim as they are more prone to develop depression and anxiety, and they are more likely to have adverse health outcomes, be impoverished, have reported police contact, and have low educational attainment as adults (Copeland et al. 2014; Stringaris et al. 2018).

Several behavioral treatments have been developed to target disruptive behaviors and irritability in children with and without ADHD, including parent training programs. Parent training programs are effective in the treatment of some impulsive behaviors in ADHD and disruptive behaviors in children and are included in the recommendations set forth by the National Institute for Health and Care Excellence and the American Academy of Pediatrics (Faltinsen et al. 2019; Wolraich et al. 2019). However, despite these guidelines, families often lack access to evidence-based behavioral interventions; children with disruptive behavior and children with ADHD are often prescribed psychotropic medication without receiving behavioral interventions (Kazak et al. 2010; Danielson et al. 2018; Walls et al. 2018).

Barriers to obtaining parent training are numerous, including distant location, lack of transportation, high costs, limited insurance coverage, parents' limited time availability, need for child care, lack of trained staff, stigma, and skepticism of the pediatric mental health system (Lundahl et al. 2006; Baker et al. 2011; Thornton and Calam 2011; Weisenmuller and Hilton 2020). In a systematic review of engagement across 262 studies of parent training programs, Chacko et al. (2016) found that even among families with access to parent training, parent engagement is limited and attrition rates are high, with at least 25% of participants meeting inclusion criteria declining to enroll and an additional 26% dropping out during treatment. The authors note that these are likely underestimates and that attrition was significantly higher in samples with low socioeconomic status.

To overcome barriers to high-quality care, online versions of parent training (Digital Parent Training [DPT]) have been developed and tested (Olfson et al. 2014; Baumel et al. 2017; Thongseiratch et al. 2020). The majority of these programs provide only self-directed content, which may include “non-interactive” content, such as podcasts and videos, or “interactive” content, such as multiple choice questions with feedback, workbooks, downloadable material, chat boards, and emails (Baumel et al. 2017). A number of self-directed DPT interventions have been shown to reduce child behavior problems and improve parental mental health, particularly not only for families of children with subclinical problems (Day and Sanders 2018; DuPaul et al. 2018; Thongseiratch et al. 2020) but also for families of children with behavioral symptoms in the clinical range (Enebrink et al. 2012).

When compared with in-person parent training, self-directed DPT programs have been found to be less acceptable to parents (DuPaul et al. 2018; Breider et al. 2019), and in some cases, they have been associated with higher attrition rates and less improvement in child behavior (Breider et al. 2019). Self-directed DPT programs with no direct therapist involvement do not provide opportunities to build the therapeutic alliance that is so valuable to clinical outcomes (Wampold 2015). It is unclear whether self-directed DPT programs can meet the needs of children with more significant levels of disruptive behavior and/or families who are seeking in-person clinical services for their child's disruptive behavior (Breitenstein et al. 2014; Thongseiratch et al. 2020). Thus, we developed a novel approach that combines digital content with videoconference coaching, aimed at improving access to evidence-based behavioral treatment for families seeking psychiatric services for child disruptive behavior.

Several existing DPT programs augment online, self-guided modules with telephone consultations (Franke et al. 2016; Sourander et al. 2016). There is evidence that DPT programs with professional support are superior to DPT programs with primarily self-guided content. Day and Sanders (2018) compared a self-guided DPT program with the same online DPT program enhanced by eight brief (M = 23 minutes) weekly telephone consultations with a trained practitioner. While families receiving self-guided DPT did show improvement in child behavior and parenting practices post-intervention, the telephone-supported DPT showed higher completion rates, greater parent satisfaction, and a greater and more sustained effect on child behavior and parenting practices. Rabbitt et al. (2016) compared a “full-contact” internet-based parent management training program, which entailed eight 50-minute treatment sessions via videoconference, with a “reduced-contact” program, which combined eight pre-recorded online sessions with brief bimonthly phone calls from the therapist. Although the two programs were similarly effective at improving child behavior, attrition was higher and acceptability ratings were lower in the condition with reduced therapist contact.

These studies suggest the value of professional support in DPT programs. Further, DPT interventions that combine self-directed content with individualized clinical care may afford the opportunity to identify specific treatment needs early and to refer children to a higher level of care when needed.

The purpose of this open trial was to test the feasibility, acceptability, and clinical effects of a novel intervention for irritability and disruptive behavior in young children called “Tantrum Tool.” Two elements are unique to Tantrum Tool. First, it includes twenty-six 12-second animations of parent–child dyad interactions to illustrate the strategies or parenting skills that are taught in each module. Second, the format of parent training delivered online via animated examples combined with three videoconference sessions condensed the duration of the program, resulting in a more time-efficient delivery—eight 10-minute online modules completed by the families plus three 45-minute videoconferences—as opposed to the 7–12 hours of clinical time allotted in other parent training interventions that incorporate videoconferences with clinicians (Rabbitt et al. 2016; Thongseiratch et al. 2020).

Methods

Study design

This prospective single-arm open trial was performed at the Yale Child Study Center between October 2018 and December 2019. This study was approved by the Yale Institutional Review Board (IRB, protocol number 0102012121) and it was registered in ClinicalTrials.gov (NCT03697837).

Participants

Male and female children, ages 3–9 years old, were eligible to participate in the study. Although temper tantrums are common in 3-year-olds, severe and/or frequent tantrums can be developmentally inappropriate, and families may seek treatment (Wakschlag et al. 2007). The age range from 3 to 9 years was selected because the general principles of parent training for disruptive behavior are largely the same across this age span.

Further inclusion criteria were as follows: A Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5; American Psychiatric Association 2013) diagnosis of ODD or conduct disorder was required to participate, based on assessment with the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) and confirmed by clinical interview (Kaufman et al. 1997). Of note, studies show consistency between preschool psychopathology assessments and KSADS administered for young children (Birmaher et al. 2009). A score of >3.6 in the Affective Reactivity Index (ARI) parent report was also needed for inclusion in the study. This cut-off value is the mean for children with severe irritability (Stringaris et al. 2012). Further, parents required access to a mobile device and/or computer device, and they needed to be native English speakers and agree not to initiate new mental health treatments for their child for the duration of the study. Participants were excluded if they had received parent training previously, or if the child had a medical or psychiatric condition that required immediate clinical attention.

Participants were recruited by using announcements at local outpatient child mental health services as well as by contacting local pediatricians' offices and schools and posting flyers in public libraries. Initial screening was conducted by telephone, as approved by the Yale IRB, to describe the study to potentially interested parents and ensure that the children were within the appropriate age range, spoke English, and were not undergoing active changes in mental health treatment that would exclude them from this trial. Thus, participants agreed not to undergo medication changes while they were enrolled in the study. After telephone screening, parents were invited for an in-person assessment visit to confirm eligibility, collect subject characterization data, and establish baseline for outcome measures. Written informed consent was obtained from a parent or legal guardian, and assent was obtained from the children at the beginning of the visit. Parents received compensation for attending the pre- and post-treatment assessments.

Measures

Acceptability was measured by tracking treatment retention and administering the Patient Satisfaction Questionnaire (PSQ) at the post-treatment assessment visit (Larsen et al. 1979). The PSQ measures patient satisfaction and consists of eight items, each scored on a scale of 1–4, where a score of ≥3 is considered “acceptable.” PSQ total scores range from 8 to 32. This measure has high internal consistency and has been frequently utilized to assess acceptability of behavioral interventions (Larsen et al. 1979; Miklowitz et al. 2015; Hyland et al. 2019).

Clinical effects were gleaned by administering the following assessments at the initial visit and at the post-treatment visit: the Disruptive Behavior Rating Scale (DBRS) (Barkley 2013) and the ARI (Stringaris et al. 2012). The DBRS is an eight-item measure of ODD rated by the parent or caretaker on a 0–3 scale. Scores from 0 to 3 are defined as “never or rarely,” “sometimes,” “often,” or “very often.” By convention, a score of 12 is considered clinically significant. The ARI is a seven-item measure of irritability in children and adolescents where items are scored on a 0–2 scale. The total ARI irritability score is the sum of the first six items, with a possible range from 0 to 12. Demographic information was also collected.

A clinical interview with the parent and child was carried out by a psychiatrist specializing in children and adolescents with prior training in the reliable administration of a semi-structured KSADS. Children and parents also discussed their presenting concerns with experienced child psychiatry fellows to ensure appropriateness of the study intervention for the overall level of symptom severity and impairment. At the end of the 8-week online intervention, parents were invited to a post-treatment assessment visit.

Intervention

The intervention was developed by co-authors D.G.S., PhD, an expert in irritability and parent management training, and D.G., MD, a child psychiatrist specialized in online treatments. It consisted of eight modules delineating the principles of parent management training, augmented by three videoconference sessions with clinicians.

After the initial in-person study visit, eligible participants were given instructions to access the Tantrum Tool online. In addition, parents were taught to use a behavioral observation chart (see sample chart in Supplementary Table S1). They were instructed to use the chart ∼60 minutes per day for a week to identify when their children had behavioral problems such as “did not listen the first time.” Basic parent management training concepts were also introduced at the end of this visit, including monitoring of antecedents and consequences of behavioral problems and how to give effective commands to children. Parents were sent home to complete the observation chart and start the online modules.

The online component of the intervention consisted of eight interactive 10-minute modules of content describing parent training principles. Each module included three to four 12-second animations of parent–child dyads with a short explanation to convey a specific skill or strategy. Parents clicked on animations to view practical examples of each parenting skill, allowing parents to consider how best to apply the strategy to a given scenario before they clicked to the next screen. See Figure 1 for images depicting the dyads in the animations. The topics of the modules were: (1) an introduction to tantrums and “functions” of maladaptive behaviors; (2) antecedents and consequences; (3) managing triggers; (4) how to praise; (5) rewards charts; (6) giving instructions effectively; (7) praising children when behaviors are adaptive; and (8) ignoring maladaptive behaviors when possible.

FIG. 1.

Images of the animations used in Tantrum Tool online modules. (A) Child frustrated that mother asks child to brush his teeth. (B) Child crying at grocery store.

Parents completed each module at their own pace, with the option to complete up to three modules in one sitting. The Tantrum Tool platform enabled the research team to track parents' progress remotely, and it triggered a message to the research team when parents completed a block of modules (two or three modules per block). At this time, the family was contacted to schedule a videoconference.

Three 45-minute videoconferences were held approximately every 2 weeks, after module 3, module 6, and module 8. Videoconferences were held with a child psychiatry fellow to apply the principles of parent management training that the parents were learning online to the targeted disruptive behaviors that parents identified as most problematic. The videoconferences were held on Zoom, a university-supported platform compliant with the Health Insurance Portability and Accountability Act. Participants accessed videoconferences using a link generated by the research team. The three videoconferences were conducted by using a structured plan that included the topics covered during digital modules. Table 1 delineates the content of each online module and videoconference.

Table 1.

Tantrum Tool; Online Module and Videoconference Content and Order

Module 1. Introduction to Tantrums:

Parents learn that tantrums are a form of communication. Parents observe the frequency of their child's tantrums.

Module 2. ABCs of Behavior (Antecedent, Behavior, Consequence):

Parents learn that tantrums have antecedents, or triggers. Parents practice identifying the antecedent of a tantrum; for example, a request to stop playing and brush teeth.

Module 3. Manage the Triggers:

Parents learn strategies to manage triggers and practice an approach that works for their family routine. Behavior observation chart is introduced.

Videoconference 1

• Review behavioral observation chart.

• Review concepts: observable behaviors, effective commands, antecedents/consequences of behavior, praise/rewards.

• Introduce reward chart concept.

Module 4. First Things First:

Parents learn to manage the child's environment and surroundings. Parents practice identifying their own stress and emotional distress.

Module 5. Rewards:

Parents learn about effective rewards for their child's positive behavior, including praise, object-based, and relationship-based rewards.

Module 6. Positive and Opposite:

Parents learn that appropriate commands need to be specific and express the desired behavior; for example, instead of saying “Stop shouting!,” whisper “Speak with your inside voice please.”

Videoconference 2

• Review behavior and reward charts; provide feedback and identify barriers.

• Review progress on primary targeted behavior.

• Discuss concept: planned ignoring.

• Identify behavior to target with behavior chart for the next 1–2 weeks.

Module 7. Catch ‘em Being Good:

Parents learn to praise children when they spontaneously do positive things; for example, “You are playing so nicely!”

Module 8. Planned Ignoring:

Parents learn about strategic ignoring of minor misbehaviors, while praising positive behaviors, to make the undesired behavior go away.

Videoconference 3

• Review behavior charts with a focus on changes in frequency/intensity of target behaviors.

• Review tools described online and in-past videoconferences.

• Discuss positive changes observed by parents.

• Plan for other behaviors and foresee future challenging scenarios.

The first videoconference included a discussion of observable behaviors and giving effective commands. For example, parents were given examples of making positive requests, such as “please use inside voice” rather than “stop yelling.” The behavioral observation chart that parents had completed in the first week of treatment was also reviewed during the first videoconference, and specific feedback on target behaviors was provided. The discussion focused on antecedents and consequences of the behavior and how positive consequences for positive behaviors, such as praise and rewards, can be utilized to reduce the frequency and intensity of targeted disruptive behaviors. Finally, a simple reward chart was designed for one of the child's disruptive behaviors identified by parents as problematic.

During the second videoconference, clinicians reviewed the behavior and reward charts with parents, providing feedback and identifying solutions to difficulties parents encountered. The progress on the primary targeted behavior was reviewed, and successful parenting strategies were identified and applied to the next targeted disruptive behavior. In parallel with the topics that parents were learning on the digital platform, “planned ignoring” of minor misbehaviors (such as whining or pouting) was discussed and related to the parent's current observations of their child's behavior.

During the third videoconference, the behavior charts were reviewed with a focus on changes in the frequency and intensity of targeted disruptive behaviors. The session included a discussion of any positive changes observed by parents and a review of all the tools described in the online and videoconferences. Finally, clinicians helped parents plan for other behaviors as well as foresee challenging scenarios.

A structured script for each of the videoconference sessions was followed by all clinicians. Treatment fidelity was maintained with written session notes to ensure adherence to the structured script, and thorough discussions of each case were held at biweekly team meetings with the research team clinical supervisor. The intervention was delivered by three child psychiatry fellows and supervised by a senior child psychiatrist, all of whom had prior clinical training in parent management training. This clinical training consisted of ten 1-hour weekly sessions and supervision of parent training that they conducted for clinical cases of children with disruptive behavior.

Analysis

The benchmarks for feasibility of this intervention were proposed before initiating the study. The intervention would be deemed feasible if 80% or more of participants completed all modules and attended two of the three videoconference sessions, given that attrition rates in similar interventions are often >25% (Chacko et al. 2016). The intervention would be deemed acceptable if >60% of parent responses were 3 or 4 in the PSQ, which correspond to “Slightly Agree” or “Agree” with positive statements on the eight acceptability items. Results for these outcomes are reported with descriptive statistics, including mean and standard deviation. Finally, regarding clinical effects, the team hypothesized that after the intervention parents would report a ≥ 35% reduction in DBRS score, which is the threshold for clinical significance in studies that use a similar eight-item measure of oppositional defiant disorder (ODD) symptoms (MTA Cooperative Group 1999; Swanson et al. 2001; Scahill et al. 2006). Also, given the large effect size of parent training interventions reported across meta-analyses (Comer et al. 2013; van Aar et al. 2017), we proposed that a significant reduction in DBRS scores would be present in at least 60% of children.

Regarding correction for the probability of Type I error, we designated DBRS as our a priori primary outcome measure. Therefore, we first tested the change in the DBRS total score from baseline to endpoint by using a paired t-test with a two-sided alpha level set at 0.05. Then, for the exploratory outcome measure of irritability (ARI), we set the alpha level at 0.025.

Results

Participants

Seventeen subjects were consented and 15 met inclusion criteria and were enrolled in the study. Two subjects did not meet criteria for enrollment due to high acuity of clinical needs and were referred for treatment elsewhere (Fig. 2). Thus, the study sample included 15 children, 13 boys and 2 girls, in the age range from 3 to 9 years (Mean = 5.2 years, standard deviation [SD] = 1.5). All children met criteria on KSADS and diagnostic evaluation for disruptive behaviors. Of note, the children included in this study had irritability levels above the typical range for their age group. Seven children met criteria for ODD, seven others met criteria for DMDD, and one met criteria for disruptive behavior disorder not otherwise specified (DBD-NOS). In accordance with DSM-5, the diagnosis of DMDD was assigned to children who met criteria for both ODD and DMDD. In addition, seven children had ADHD and two children had post-traumatic stress disorder (Table 2). One-third of the children had already either received a prior referral or received mental health treatment for their level of irritability.

FIG. 2.

Flow of patients through the open trial design of digital parent training.

Table 2.

Summary of Demographic and Clinical Characteristics of the Study Sample at Baseline

	Baseline (n = 15)
Child age, mean (SD)	5.2 (1.5)
Child sex, number (%)	86.7
Male	13 (86.7)
Female	2 (13.3)
Race, number (%)
Asian	1 (6.7)
Black or African American	1 (6.7)
White	12 (80.0)
More than one race	1 (6.7)
Ethnicity, number (%)
Hispanic or Latino	0 (0)
Not Hispanic or Latino	15 (100)
IQ, mean (SD)	106.5 (14.6)
Taking psychiatric medication, number (%)	1 (6.7)^a
Diagnosis, number (%)
ADHD	7 (46.7)
ODD	7 (46.7)
DMDD	7 (46.7)
DBD-NOS	1 (6.7)
Anxiety	5 (33.5)
Depression	1 (6.7)
PTSD	2 (13.4)
ARI total score, mean (SD)	7.1 (2.4)
DBRS total score, mean (SD)	14.2 (5.3)

Participant was on risperidone at a stable dose for 4 weeks before enrollment in the study.

ADHD, attention-deficit/hyperactivity disorder; ARI, Affective Reactivity Index; DBD, disruptive behavior disorder; DBRS, Disruptive Behavior Rating Scale; DMDD, disruptive mood dysregulation disorder; IQ, intelligent quotient; NOS, not otherwise specified; ODD, oppositional defiant disorder; PTSD, post-traumatic stress disorder; SD, standard deviation.

Feasibility and acceptability

A total of 13 of 15 subjects (87%) completed all the online modules. Thirteen subjects completed all three videoconferences, whereas two families completed only one or two videoconferences. The videoconference completion rate for all participants combined is 91%. One of the participants who completed the intervention did not attend the endpoint visit. All the parents who completed the intervention and attended the endpoint visit (12/15) rated the intervention as acceptable or very acceptable on 7–8 of the 8 PSQ items. The mean PSQ score was 26.5 (SD = 2.7) (Table 3).

Table 3.

Patient Satisfaction Questionnaire Item-Level Data

PSQ items	Score, ^a M (SD)(n = 12)
Item 1. How would you rate the quality of help you wanted for your child?	3.4 (0.7)
Item 2. Did you get the kind of help you wanted for your child?	3.2 (0.4)
Item 3. To what extent has the program met your child's needs?	2.7 (0.7)
Item 4. If a friend's child were in need of similar help, would you recommend the program to him/her?	3.7 (0.5)
Item 5. How satisfied were you with the amount of help your child has received?	3.3 (0.5)
Item 6. Has the help your child received helped your child to deal more effectively with his/her problems?	3.4 (0.5)
Item 7. In an overall, general sense, how satisfied are you with the help your child has received?	3.3 (0.5)
Item 8. If you were to seek help again for your child, would you come back to our program?	3.7 (0.5)
Item 9. Please rate your satisfaction with the program on a 1–10 scale, where 1 is not at all helpful and 10 is very helpful.	8.5 (1.4)

Items 1–8 are scored on a scale of 1–4; higher scores indicate higher satisfaction. Item 9 is an overall satisfaction score on a scale of 1–10.

PSQ, patient satisfaction questionnaire; SD, standard deviation.

Disruptive behavior and irritability

There was a significant reduction in mean DBRS score from 13.5 (±5.5) at baseline to 7.3 (±3.4) at endpoint (p < 0.001) among the children who completed the study (Fig. 3). This difference of six points on DBRS represents a 46% reduction in disruptive behavior ratings, which is also a clinically meaningful reduction that is consistent with our prediction. Ten of the twelve children showed clinically significant improvement as reflected by >35% reduction in DBRS scores. The ARI results reflected a similar change from 7.2 (±2.6) at baseline to 3.75 (±2.1) at endpoint (p < 0.01) among the children who completed the study (Fig. 3). This is a 48% reduction in ARI scores from the levels of irritability that children had at baseline.

FIG. 3.

Reduction in mean DBRS score (A) and mean ARI score (B) from baseline to endpoint. Error bars represent standard error. **p < 0.01; ***p < 0.001. ARI, Affective Reactivity Index; DBRS, Disruptive Behavior Rating Scale.

Discussion

This study examined the feasibility, acceptability, and clinical effects of an individualized DPT treatment for children with irritability and disruptive behaviors. The feasibility of this online treatment is endorsed by the high rate of online module completion (>80%) and attendance to videoconferences. The dropout rate is relatively low (20%) and consistent with in-person studies of parent training for disruptive behavior, estimated at 26% (Chacko et al. 2016). The reasons for dropout are unclear but, in both cases, parents appeared to have difficulty scheduling the phone calls within working hours of the study clinicians (8 a.m.–5 p.m. on weekdays).

Strong ratings on the PSQ suggest that the treatment is highly acceptable to participating parents. General themes of parents' feedback included appreciation of individualized guidance to implement recommendations for their children's circumstances, the importance of regular intervals between videoconferences to encourage consistency in their adherence, and more willingness to seek mental health care in the future if the need arises. Parents expressed satisfaction, as they were able to review the modules and have videoconference sessions at convenient times without having to arrange for travel to the clinic. Specifically, some parents were able to schedule sessions while their children napped or were at school, or during their lunch breaks at work, allowing for both parents to participate even when they were in different places. Another area of satisfaction included the positive effects of brief and targeted coaching. Although most PSQ items had mean scores above 3, it appears that parents perceived that some of their needs remained unmet as evidenced by a score of 2.7 out of 4 on item 3. Unstructured interviews with parents at the endpoint visit suggested a variety of possible reasons for this score, ranging from wishing they would be sent a reminder or “booster” a few months later, needing help with a sibling's behaviors, or wishing clinicians would collaborate with schools to extend the implementation of behavior charts at school after parents had observed a positive change at home.

An assessment of the change in DBRS scores of enrolled participants suggests that children's disruptive behaviors can clinically improve with this intervention. As noted by a reduction in the ARI scores, there was also improvement in the children's level of irritability.

The Tantrum Tool holds promise to support parents who are unable to access traditional, in-person parent management training for their child. As this is an open feasibility study, we cannot confirm, and did not presume, that the change in clinical symptoms was due to the Tantrum Tool rather than parents' expectations or attention from study personnel. Nevertheless, the reduction of >35% in DBRS scores among 10 of the 12 participants is consistent with the clinical effects observed in in-person parent training studies.

In addition to improving access to treatment for parents, with the Tantrum Tool more clinicians may be able to provide parent training to their patients as evidenced by the involvement of child psychiatry fellows in the delivery of this intervention. This is, in part, afforded by the reduced clinical hours required by the Tantrum Tool.

Of note, the numerous calls that were screened demonstrate the high need for parent training treatments in the community. A significant portion of callers were limited by the requirement of in-person visits, but it remains unclear whether offering solely online assessments would suffice. Nevertheless, at the post-intervention visit, most participants favored keeping an in-person baseline visit rather than carrying it out exclusively online. The value of the in-person visit should be assessed in future studies.

From an assessment point of view, the combination of a platform with general content with videoconferences to individualize the skills garners much value. The online videoconferences provide opportunity for a “naturalistic” observation in ways that are otherwise missed in a clinical setting. For instance, during videoconferences, the disruptions of neighbors or siblings and the logistical challenges of the house set-up became more apparent. Further, a brief online intervention serves as a thorough, low-cost assessment of patients' and family's needs, strengths, and vulnerabilities, gauging whether parents and patients would be able to engage in routine therapy. Finally, after online treatment, parents often reported more willingness to engage in in-person care, suggesting that telebehavioral health may help reduce stigma.

This study's small sample size limits the conclusions that can be drawn regarding parents' ratings of acceptability. Another limitation is the lack of control condition for comparison, which precludes assessments of effectiveness. The required in-person visits limit the central premise behind the design of the digital Tantrum Tool, as the same barriers that limit access to standard care may also limit the access to participation in this study trial. Another limitation is the lack of a follow-up visit after 3 or 6 months to assess the durability of symptom improvement that were observed in the trial. Finally, sessions were not recorded for this small pilot study. Incorporating video-recording for independent treatment fidelity ratings will be important in future studies. These limitations can be addressed in larger, randomized controlled trials designed to evaluate the efficacy of the Tantrum Tool.

Another important limitation of this study is a relatively wide age range (3–9 years) of study participants and lacking sample size to investigate heterogeneity of subject characteristics that can be associated with irritability in this age group. The Tantrum Tool could be helpful for children with frequent and impairing tantrums that occur in the context of DBD as a primary diagnosis. The presence of more pressing psychiatric disorders that require different treatment is one of the exclusionary criteria for the study. Indeed, several families had to be referred to the child psychiatry clinic as their symptoms were deemed inappropriate for the study. Future larger studies could address this question of heterogeneity of study participants with a priori nominated subject characteristics (such as age, gender, or presence of co-occurring conditions) that could be used to stratify the sample and to conduct planned moderation analysis.

Conclusions

This individualized DPT Tantrum Tool is a promising intervention for children with irritability and disruptive behavior that can improve access, via an online platform and videoconference coaching, to evidence-based behavioral treatments that may not be easily available face-to-face. A randomized control trial of this online program is warranted to confirm clinical efficacy and effectiveness. In the future, online treatments may be an excellent avenue to improve access to care, not only for families in rural communities but also for those who cannot access care due to work schedules, logistical difficulties with childcare and commute from home, or stigma.

Clinical Significance

The Tantrum Tool is an online behavioral intervention that child psychiatrists and pediatricians can deliver in three telehealth sessions with a high level of treatment fidelity, improving access to first-line treatment of disruptive disorders in children.

Footnotes

Acknowledgments

This work was made possible thanks to the American Academy of Child and Adolescent Pilot Research Award for Attention Disorders, supported by AACAP's Elaine Schlosser Lewis Fund, the National Institute of Mental Health (NIMH T32 MH018268-34), and the Yale Child Study Center Faculty Development Fund. The authors thank Elif Tongul for her help with this study. Finally, they are most grateful to the families who participated in this study for contributing their time and for being willing to share their experiences with the authors.

Disclosures

D.G., MD is a founder of MindNest Health, a digital health company that focuses on pediatric behavioral health. D.G.S., PhD receives royalties from Guilford Press. A.D.-S., MD, S.R., and E.Z. have no disclosures.

Supplementary Material

Supplementary Table S1

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