Using Home-Program Adherence App in Pediatric Therapy: Case Study of Sensory Processing Disorder

Abstract

Background:

Pediatric therapies adopt a family-centered approach that encourages a caregiver's involvement in therapy. Contextual interventions in the child's natural environment have been effective in generalization of skills and increasing of child participation in daily activities. The use of home programs is common across a variety of conditions, but adherence has been challenging. Apps have been demonstrated to promote medication adherence and physical activity maintenance.

Introduction:

This study suggested and tested a construct for features required for caregivers' behavioral modification during home programs in pediatric therapy.

Materials and Methods:

SensoryTreat is an adherence promoting app for home-program treatments of children with sensory processing disorders. The app was evaluated by testing availability of desired features, usage frequency, impact on adherence with home programs, and parental sense of competence.

Results:

Results suggest a strong significant correlation between SensoryTreat usage frequency and families' adherence with home programs, as well as a strong significant correlation between relevancy and usefulness of SensoryTreat's interventional content, and parental competence and their adherence with home programs.

Discussion:

Using SensoryTreat twice or more per week increases parental adherence with home programs. Content plays an important role in promoting adherence and parental sense of competence, yet, as usage frequency grows the interventional content habituates, and other features as goal setting and feedback logs have significant impact on parental competence and adherence with home programs over time.

Conclusions:

These findings indicate that the content and features of SensoryTreat app have the potential to promote adherence of families with pediatric therapy home programs.

Introduction

Family-centered therapy cultivates positive relationship between therapist and caregivers and encourages participation of parents in their child's interventional home program, while collecting data for data-driven decision-making.¹ According to the ecological model, families are the most influential factor on the child,² and contextual interventions in the child's natural environment bear lasting impact.³ Intersession home programs have been demonstrated as effective in several fields such as autism spectrum disorder (ASD),³ cerebral palsy,⁴ sensory processing disorder (SPD),⁵ psychotherapy,⁶ pediatric rehabilitation,⁷ intellectual disabilities,⁸ and more. However, studies on home programs have also shown low adherence rates stemming from lack of time, support or skills, competing demands, psychological issues, and expectations regarding the roles of parents and therapists.^9,10 Home program adherence assessment has also been a major challenge using both objective and subjective measures.¹¹ Another challenge is the need to customize the content of interventional home programs for each family and to adapt those over time.¹² Such complexities are aggravated in families of children with special healthcare needs that face irregular and often unmet requirements for health related services.¹³

The use of apps in healthcare has been growing and today, there are over 259,000 m-health apps available on App Store and Google Play.¹⁴ Most parents today are Millennials (i.e., Generation Y born between the 1980's and 2000) who use smartphones to manage most aspects of their lives, including healthcare,^15
–17 making apps an ideal tool to help drive family engagement in the child's home program. Studies to date have focused on using apps mainly for medication adherence,¹⁸ physical activity,¹⁹ and dietary regimens.²⁰ Studies on apps for medication adherence have mapped behavioral modification features that include: reminders (i.e., “what” to take), monitoring/tracking progress over time, sharing user adherence history, goal setting and monitoring, positive reinforcements, solutions to barriers, and linking medication taking with established routines.¹⁸ Other studies have measured apps against structured behavior change techniques such as action planning, prompts/cues, self-monitoring, feedback on behavior (including reasons for skipping), monitoring by others, social support, examples and explanation (i.e., “how”), practice/rehearsal, social comparison, and information about adherence benefits.²¹

In studies on apps that promote maintenance of physical activity, the Health Action Process Approach (HAPA) considers two phases of health behavior change: (1) motivational/intentional phase representing one's intention to change health behavior and (2) volitional phase, representing the actual taking of action,¹⁹ stating that it is not obvious that once intention is expressed, the actual action will follow. The “intention-behavior gap” is bridged by three types of social cognitions: (a) detailed action planning (e.g., “when” and “where”), (b) perceived self-efficacy (e.g., coping strategies), and (c) self-regulation strategies (e.g., action control).²² Other studies have shown that modeling (e.g., showing “what” to do) was a good predictor in apps promoting physical activity for children.²⁰ Comparing groups of app users versus nonusers, Bassett-Gunter et al. suggest that app users have greater social cognitions such as self-efficacy, planning, goal setting recovery, and action control.¹⁹

While studies addressed the use of apps in medication and physical activity adherence, little has been written on the use of apps to promote adherence with pediatric therapy home programs.²³ However, principles of adherence promoting apps in other areas may be applied, with relevant adjustments, to pediatric therapy to encourage adherence with home programs.

In pediatric rehabilitation, models for family-professional collaboration that is essential to optimize therapy outcomes include the following: family-identified needs, shared responsibility, and family empowerment in four steps: (1) mutually agreed-upon goals, (2) shared planning, (3) shared implementation, and (4) shared evaluation.⁷

In pediatric occupational therapy, therapists that practice a family-centered approach utilize the following theoretical constructs to generalize child's performance and transfer children's skills into their natural environments: (1) coaching to problem solve,³ (2) consulting to support, (3) contextual interventions in natural environments, (4) motor learning principles for generalization, and (5) social skill groups.¹

Novak suggested a model for development of home programs for children with cerebral palsy, including: (1) establishing partnership with parents; (2) setting goals; (3) constructing the home program that focus on these goals; (4) supporting parents in implementation; and (5) evaluating outcomes.²⁴

In children with SPD and specifically sensory modulation disorder (SMD) individual sensory strategies are designed to enable participation of the child in everyday activities. Hyper and hyporesponsivity to sensory stimuli are considered today as part of the ASD diagnosis²⁵ and have been shown to have comorbidities with attention deficit hyperactivity disorder (ADHD)²⁶ and Tic Disorder.²⁷ Sensory Integration treatment, such as adaptive sensory stimulation activities, has been proven effective in treating children with SMD.^28,29 In another randomized controlled trial (RCT) study, individually tailored activities based on a sensory motor assessment of the child were proven effective in treating children with ASD.³⁰ Administering sensory inputs by parents at home, based on the child's sensory profile and a therapist designed program, together with therapeutic listening interventions, has been proven effective in children with SPD and visual-motor delays.³¹ The challenge has been to promote adherence with the home program, which in simple terms can be defined as helping the family do their “excessive homework”.

The SensoryTreat app is designed to assist families of children with SPD, up to the age of 12 to manage home programs that are part of an inclusive occupational therapy intervention. The SensoryTreat app provides users with a program to adapt their environment and activities to address their child's over or under reactivity to sensory inputs in the various sensory modalities. Designed as an adherence promoting app, it aims to leverage family home program behavioral modification features such as notification reminders, goal setting, detailed planning, self-monitoring, and so on. Tailored specifically for the pediatric therapy space, the SensoryTreat app is also content “rich,” with a variety of color coded activities illustrated in playful manner and provided as a content “bank” for therapists to choose from when designing the individualized home program.

In this study, we applied principals of adherence promoting apps used in fields such as medication adherence and physical activity to therapeutic home program design and monitoring, in pediatric therapy. We then evaluated the SensoryTreat app by testing availability of adherence-promoting features and the impact of using the SensoryTreat app on adherence with the home program and parental sense of competence.

Materials and Methods

Participants

Forty-five (n = 45) parents of children with SPD who were treated by occupational therapists participated in this study. Half of the children were boys and half were girls. Mean age = 4.31 and age SD = 2.10.

All of these parents used the SensoryTreat app as part of their children's occupational therapy. Inclusion criteria were as follows: (1) users that are parents of children under the age of 12 and (2) parents who have been actively using the app during the 4 months preceding the start of the study. Parents who did not login to the app since their registration or parents whose subscription ended more than 4 months before the study were excluded from the study.

Instrumentation

SensoryTreat usage data

In this study we extracted usage frequency data on app logins and on specific features, for all participants. Specifically, we extracted data on the following: number of user logins per month of use, number of daily scheduled activities, number of feedback logs provided, number of goals scored per month of use, number of positive reinforcement messages, number of shares with therapists, child age, and subscription term.

App impact questionnaire

App impact questionnaire (AIQ) is a seven-item scale that was developed specifically for this study, to assess the app's impact on adherence and sense of competence of the parents.

Step 1: Compilation of items

The AIQ was developed using two steps as follows: first the relevant theoretical and clinical literature about adherence was reviewed. The second source included lists and questionnaires that address evaluation of technological applications for children.

Step 2: Examination of the AIQs content validity and internal consistency

A focus group of three occupational therapists familiar with the SensoryTreat and experienced with the use of technologies in assisting families of children with developmental disabilities was conducted. Therapists were asked to assess whether statements about adherence to the use of technology may apply to the SensoryTreat application.

Finally, responses of a pilot of 20 parents to the questionnaire were reviewed. Questions that were ignored or resulted in a response of N/A in more than 50% of the parents were omitted from the questionnaire.

The last version of the questionnaire was assessed using 45 parents who constructed the study's sample. Based on this sample—internal consistency of the AIQ scale was tested to be alpha = 0.88.

Procedure

The app was presented at the American Occupational Therapy Association (AOTA) Annual Conference as a tool for helping families manage sensory diet (i.e., home program of SPD therapy). Therapists were invited to recommend the app to families they treat without any incentives or benefits, other than their professional satisfaction that it can help families. Ethical approval was received from the University of Haifa's ethical board. All the subscribed app users and active trial users, totaling 787 app users, were approached through email inviting them to participate in the study. Users were then referred through link to a form using Typeform Web-based system where they first granted consent to participate in the study and were then presented with the questionnaire. Of the 787 users, 128 started filling out the form, and 54 completed filling it out. Nine users were disqualified due to not meeting the inclusion criteria. App usage data were extracted for all users, and analysis was conducted for the remaining 45 participating users. The two data sources were matched using anonymized ID's.

Statistical Analyses

Descriptive statistics was used to describe usage frequency of the app's features.

Spearman Rho correlation analysis was used to determine correlations between usage of the app features and the families' reported outcomes captured by the AIQ scale, as well as between various items of families' reported outcomes.

Mann–Whitney test was used to compare groups of different usage frequencies of app's features, in terms of family reported outcomes captured by the AIQ scale.

The IBM Statistical Package for the Social Sciences (SPSS) (version19) was used for all statistical analyses.

Results

Our result section includes two parts as follows: (1) description usage frequency of the app features and (2) statistical analysis of the relationship between actual usage of app's features and family reported outcomes as captured by the AIQ scale and among the different factors of the AIQ scale.

Part 1-Feature Usage

The pediatric therapy adjusted list is presented at Table 1 below, along with the evaluation of features' existence in the SensoryTreat app, the number of users who used each feature, and their usage frequency.

Table 1.

Usage of Behavioral Modification Features on the SensoryTreat App

BEHAVIOR MODIFICATION FEATURE (EXPRESSION IN THE SensoryTreat APP)	NUMBER OF USERS WHO USED THE FEATURE (IN %)	FREQUENCY OF USAGE
Action planning (“when” and “where”) (daily schedule of activities, specific times)	89	Daily
Modeling and reminders (“what”) (local notification system)	89	Daily
Solutions to barriers/coping strategies (alternatives for activities for various situations)	89	Daily
Link to existing routines (NA^a)
Self-monitoring (summary views)	78	Weekly or higher
Feedback (including reason for skipping) (happy/sad faces plus notes for each activity)	9	Daily or higher
	44	Up to weekly
Positive reinforcement (encouragement messages)	9	Daily or higher
Positive reinforcement (encouragement messages)	44	Up to weekly
Goal setting and tracking (editable weekly scales for target scores)	49	Monthly or higher
	22	Up to monthly
Collaboration with therapist (button for sharing summary screens)	7	At least once

This feature was added to SensoryTreat after the study was conducted.

In summary: action planning, modeling and reminders, solution to barriers, and self-monitoring exhibited high rates of usage; goal setting and monitoring exhibited moderate rate of usage; and feedback, positive reinforcements, and collaboration with therapists exhibited low rates of usage.

Part 2-Statistical Analysis

Spearman Rho correlation and Mann–Whitney test analysis were used to compare usage of app's features and family reported outcomes as captured by the AIQ scale:

Results show a strong significant correlation between the number of parents' logins to the app per month ( = login_count/use_months) and their reported impact on adherence: r _s = 0.41, p = 0.006.

Parental logins per month varied significantly: mean = 15.32, SD = 19.82, median = 10.

Results further indicate that users who used the app twice or more per week, measured by the number of times they logged-in to the app during their subscription period (login_count/use_months = >7), demonstrated a significantly higher level of reported adherence in comparison with parents who used the app less than twice per week: Z = 3.36, p = 0.000 (N = 27, mean = 4.3, SD = 0.85, median = 5; compared to N = 18, mean = 3.11, SD = 1.05, median = 3).

Results indicate a strong significant correlation between the parents' reported sense of competence and between:

the usefulness of the app's interventional content: r _s = 0.46, p = 0.001; and

the relevancy of the app's interventional content to the family: r _s = 0.45, p = 0.002. A moderate significant correlation was indicated between the relevancy of the app's interventional content to the family and parent's reported impact on adherence: r _s = 0.39, p = 0.009.

Results further indicate that users who logged-in to the app every other day (login_count/use_months = >16) demonstrated significantly lower levels of reported usefulness of content in comparison to parents who logged-in to the app less frequently: Z = 2.41, p = 0.008 (N = 12, mean = 3.75, SD = 0.83, median = 4; compared to N = 33, mean = 4.42, SD = 0.95, median = 5).

Results indicate that users who used the feature of goal setting more frequently (N = 9), measured by the number of therapy goal scores submitted per month (scores_count/month_use >2), demonstrated significantly higher levels of reported adherence: Z = −1.9, p = 0.029 (N = 9, mean = 4.44, SD = 0.83, median = 5); compared to users who did not use this feature as frequently (N = 36, mean = 3.67, SD = 1.11, median = 4).

Results indicate that users who logged their child's feedback in the app's logbook consistently were a very small group (n = 4) yet more parents logged a few activities ( = >4 logged activities) indicating that they were aware of such a feature. Such parents demonstrated significantly higher levels of sense of self competence: Z = −2.23, p = 0.013 (N = 13, mean = 4.54, SD = 0.75, median = 5; compared to N = 32, mean = 3.56, SD = 1.30, median = 3.5).

Discussion

First, in consistency with literature review of apps for medication adherence and physical activity, in the context of principals from studies on adherence with home programs in pediatric therapy, this study proposed an integrated view of app features expected to promote home program adherence in pediatric therapy. Such features include: action planning (“when” and “where”), modeling and reminders (“what”), solutions to barriers/coping strategies, link to existing routine self-monitoring, feedback (e.g., reason for missing activity), positive reinforcement, goal setting and tracking, and collaboration with therapist (including monitoring by others, sharing adherence history, information about adherence benefits, social comparison, and social support). The specific implementation of these features in each app may and should differ according to the specific domain and the overall role the app plays in the therapeutic process (e.g., self-care, remote-care, home-program support, and so on).

While the SensoryTreat app includes features for most of the behavioral modifications, the results suggested that only some of the features have been frequently used. While action planning, reminders, coping strategies, and self-monitoring were frequently used, goal setting and tracking exhibited moderate usage and collaboration with therapists, feedback, and positive reinforcements exhibited only low usage. We believe this has to do with the specific implementation and user experience of such features in the app.^*

Second, this study evaluated the impact of the SensoryTreat app by analyzing actual app usage data together with the family reported outcomes as captured by the AIQ scale. When correlating user login frequency to reported adherence with home programs, results showed strong significant correlation. And when analyzing user groups according to their login frequency, results suggested that parents who login to the app twice per week or more have a significantly higher chance of increasing adherence with their home program in comparison to those who login less than twice per week. These findings indicate that the SensoryTreat app has the potential to promote adherence of families with pediatric therapy home programs.

The study further found a strong significant correlation between the level of reported usefulness and relevancy of the SensoryTreat content and the sense of parental competence, as well as a moderate significant correlation between the relevance of the content and the reported adherence with home program, suggesting that content plays a major role in promoting adherence and parental sense of competence. In pediatric therapy, and especially in the sensory motor field, individually tailored activities based on the child assessment were proven to be effective.³⁰ Coaching parents on “what” to do in the context of the child's natural environment is fundamental to parental sense of competence and adherence with home programs.³ In this context, the study found that the SensoryTreat content as used in the individualized programs of participating families has significant contribution to the parental sense of competence and their adherence with the home program.

Similarly, this study found that parents who used the goal setting feature more frequently have also reported higher levels of adherence with the home program. Suggesting that beyond features of action planning (when and where), modeling and reminders (what and how), coping strategies (alternatives), and self-monitoring, goal setting and goal monitoring have significant contribution to adherence. This finding is consistent with some of the practices of motivational interviewing techniques.³²

However, this study also found possible indications that families who use the app very frequently (i.e., daily or nearly daily) might start to find the content to be slightly less useful for them, indicating perhaps that content starts to habituate with frequent app usage. Since we see strong correlation between usage frequency and adherence, we assume that as content's role is decreasing, other features such as goal monitoring, feedback logs, and collaboration with therapist are the ones that promote adherence over time. Further research is needed to validate this point.

Another possible indication this study found states that awareness to a feedback log feature increases parental sense of competence. The low usage frequency of this feature prevents us from making strong claims, but we did see that families who used this feature a few times (indicating that they were aware of its existence) have exhibited significantly higher sense of parental competence to do their home program. Further research is needed to validate this point.

While our study is innovative by focusing on evaluating an app for promoting adherence with home programs in pediatric therapy, it is not without limitations. Our study was exposed to standard biases of questionnaires. However, the anonymity of users and the fact that it was administered by an independent academic institute for the benefit of advancing therapy research have all reduced the potential biases.

Conclusions

In conclusion, family-centered pediatric therapy relies on adherence with home programs. Apps have great potential to play a major role in promoting and measuring such adherence. Implementing behavior modification features known from fields of medication-adherence and physical-activity maintenance, in the context of pediatric therapy disciplines, could go a long way in increasing adherence with therapy home programs. In the case of the SensoryTreat app for SPD, SMD, and ASD, this study found that most desired features are represented, but with varying degrees of usage frequency. It also found that the more frequently users access the SensoryTreat app the more likely they are to adhere to their home program, with a significant step at two logins or more per week. Interventional content is known to play an important role in family's sense of competence and adherence. This study found that the SensoryTreat content as individually tailored for each family has significantly contributed to their sense of competence and adherence with home programs. And that as usage frequency increases it may start to habituate while other features promote lasting adherence, such as goal monitoring and possibly feedback log.

Footnotes

Acknowledgments

The authors thank the Israel Innovation Authority (formerly known as the Office of Chief Scientist) in collaboration with the National Insurance Institute of Israel for their grants under a special program that promotes innovation for populations with special needs, that made the development of the platform and conduction of the study possible, and to the parents that consented to participate in the study.

Disclosure Statement

E.G.: No competing financial interests exist. O.S.: Cofounder of SensoryTreat Ltd., a company that owns the rights to the SensoryTreat app.

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