This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.
Depression and anxiety disorders in young people are a global health concern. Various risk and protective factors for these disorders are potentially modifiable by parents, underscoring the important role parents play in reducing the risk and impact of these disorders in their adolescent children. However, cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. In this paper, we propose a multi-level public health approach involving a Web-based parenting intervention, Partners in Parenting (PIP). We describe the components of the Web-based intervention and how each component was developed. Development of the intervention was guided by principles of the persuasive systems design model to maximize parental engagement and adherence. A consumer-engagement approach was used, including consultation with parents and adolescents about the content and presentation of the intervention. The PIP intervention can be used at varying levels of intensity to tailor to the different needs of parents across the population. Challenges and opportunities for the use of the intervention are discussed. The PIP Web-based intervention was developed to address the dearth of evidence-based resources to support parents in their important role in their adolescents’ mental health. The proposed public health approach utilizes this intervention at varying levels of intensity based on parents’ needs. Evaluation of each separate level of the model is ongoing. Further evaluation of the whole approach is required to assess the utility of the intervention as a public health approach, as well as its broader effects on adolescent functioning and socioeconomic outcomes.
Depression and anxiety disorders are the largest contributors to disease burden in young people globally [
In young people aged between 13 to 17 years, lifetime prevalence rates of depression and anxiety disorders are 18% and 38%, respectively [
There are various reasons why the family, particularly parents, is a strategic setting for targeting prevention and early intervention for youth depression and anxiety (also known as internalizing) disorders. First, young people see their family, especially their parents, as important in their lives, especially when it comes to their own mental health. Various national surveys have found that parents are the most commonly mentioned source of help young people would turn to if and when they have mental health difficulties [
Finally, there is now robust evidence delineating risk and protective factors for adolescent anxiety and depressive disorders [
Moreover, a substantial body of research has demonstrated the various ways in which parenting behaviors may inadvertently maintain or exacerbate depression and anxiety disorders in young people [
The rest of this paper presents the rationale for developing Partners in Parenting (PIP), an individually tailored Web-based intervention for parents of adolescents. We then describe the intervention development process and explain how the various components were designed to facilitate the proposed multi-level approach to empower parents to reduce the risk and impact of depression and anxiety disorders in their adolescent children.
Below, we describe the three key reasons that motivated the development of the PIP and the proposed multi-level approach.
Existing research evidence demonstrates the value of involving parents across the mental health intervention continuum, which includes prevention (universal, selective, and indicated), treatment (case identification and standard treatment for known disorders), and maintenance (strategies to reduce relapse and recurrence, and the disability associated with the disorder) [
Preventive parenting interventions can be
Parents have an important role in facilitating case identification and professional help-seeking for adolescents. Parents are often the first to detect changes in their child’s mental health and serve as an important conduit to adolescents engaging in appropriate treatment [
Hence, we propose a multi-level public health approach involving the PIP Web-based intervention that incorporates universal, selective, and indicated prevention components, as well as treatment and maintenance components to maximize the strengths of all components to meet the needs and preferences of different families.
One important limitation of existing prevention and early intervention programs for adolescent internalizing disorders is the inadequate level and nature of parental involvement. Specifically, whereas some interventions include a parent component, this usually involves teaching parents what their child is being taught, rather than targeting modifiable parenting risk, protective, or maintenance factors [
In contrast to the increasing number of interventions targeting young people primarily [
The dearth of interventions for adolescent depression and anxiety disorders that directly target parenting factors [
Efforts to translate research evidence on the role of parenting in the maintenance of adolescent depression and anxiety may be deterred by the equivocal evidence to date regarding whether parental involvement in adolescent treatment enhances treatment effects [
Another limitation of existing parenting interventions is that many are not well-used, even when available, because of barriers such as scheduling difficulties or privacy concerns [
Web-based interventions have now demonstrated effectiveness [
An important limitation of existing prevention and treatment interventions for adolescent internalizing disorders is that they only focus on one or a few parenting risk, protective, or maintenance factors for adolescent depression and anxiety [
The PIP intervention comprises three components: (1) a parenting scale that assesses the parent’s current parenting practices and beliefs against the recommendations of the parenting guidelines; (2) an automatically generated, individually tailored feedback report based on each parent’s responses to the scale; and (3) a set of interactive Web-based modules to support parental behavior change.
To access PIP, parents register by creating an account using their email address and a self-selected password and providing basic demographic information about themselves and their child. To personalize the intervention to each parent, parents are asked to identify one target child to focus on when completing the intervention. All components of PIP are then personalized with the child’s name and gender and the parent’s name. Parents then complete the parenting scale to receive their tailored feedback report, before reviewing the selection of modules recommended specifically for them, alongside other modules (out of the nine) that are also available but were not recommended for them (because they were already considered concordant with the guidelines’ recommendations in those areas of parenting). At this point, parents can apply their own preferences by accepting or deselecting recommended modules and selecting any additional modules that were not recommended before locking in their selection and starting their personalized program. One module is unlocked every 7 days, in a predetermined order (because each subsequent module is designed to build on the content of preceding modules), until the parent has completed all of the modules in their program. The 7-day interval encourages parents to focus on achieving the goal they had set from their most recently completed module before proceeding to the next module. Parents receive an automated email informing them that their next module is available and reminding them of the goal(s) they had previously selected but not yet marked as achieved on their personalized dashboard. Each module takes 15 to 25 min to complete depending on the module and the way parents choose to engage with it. After completing all of their modules, parents gain access to all modules, including those they had not initially selected (see
The development of PIP involved three phases that were modeled after the related Parenting Strategies intervention to prevent adolescent alcohol misuse [
To identify the range of modifiable parental factors to target in the intervention, the first phase involved a comprehensive systematic review and meta-analysis of risk and protective factors for adolescent depression and anxiety disorders that parents can potentially modify or influence [
To translate this evidence base into actionable strategies, we employed the Delphi method to develop a set of expert consensus guidelines [
The resulting guidelines
The Guidelines [
To support parents in the implementation of the Guidelines, and to individually tailor the Guidelines’ recommendations to each parent, phase 3 involved developing the three aforementioned components: (1) a self-assessment parenting scale, (2) a tailored feedback report, and (3) a set of interactive Web-based modules.
Design of the Web-based components of PIP was guided by the PSD model [
First, we developed a criterion-referenced parenting scale, called the Parenting to Reduce Adolescent Depression and Anxiety Scale (PRADAS), which assesses parents’ concordance with the nine domains of parenting addressed in the nine subheadings of the Guidelines (the “criterion”; see [
Next, we wrote automated feedback messages for all possible combinations of responses to the 79 items in the PRADAS. This involved creating a scoring system and feedback flowchart linking the response options for each item to the appropriate feedback message based on the predetermined scoring algorithm. Feedback messages highlight the parent’s parenting strengths and provide specific strategies to further improve their parenting, to adhere more closely to the recommendations of the Guidelines. Feedback messages are intentionally written to be brief, with the aim of motivating behavior change by identifying areas to change and providing specific means for action (PSD tunneling principle, [
Finally, the development of the interactive modules first involved a mapping of topics to the nine domains of parenting addressed in the Guidelines (see
Attention was paid to ensure that all components of the intervention were optimized to engage parent users, following the PSD principles as far as possible (as outlined in
We recruited a reference group of 22 parents with adolescent children (aged 11-18 years) through staff e-newsletters at Monash University and the University of Melbourne, local high schools, and via online networks. Participants were mostly mothers (86.4%, 19/22), in the age range of 45 to 59 years, married or de facto, employed, Australian-born, English-speaking, and highly educated (at least an undergraduate qualification) and had 2 or 3 children. Parents attended one of three repeated 2-hour workshops (n=7 or 8 per workshop) where drafts of the PRADAS, feedback messages, and one module prototype (drafted as a Microsoft PowerPoint presentation) were presented for discussion. Parents were consulted on the language used in the PRADAS and feedback messages, and the logic, relevance, and usefulness of the feedback messages. They also provided feedback and input into the degree of interactivity and the tone and amount of content in the modules. Parents provided specific suggestions for rewording instructions and messages that could be misinterpreted or trigger unintended negative reactions from parents. Wherever possible, we incorporated parents’ feedback into all components of the intervention.
Guidelines topics, corresponding subsections of the parenting scale and personalized feedback report, title of interactive modules, outline of content, and rationale for their inclusion.
Guidelines topic | Corresponding subsection of the parenting scale and feedback report | Title of interactive module | Outline of content | Rationale for inclusion |
N/Aa; Not included in parenting scale or feedback report | ||||
Establish and maintain a good relationship with your teenager | Your relationship with your teenager | Connect | Acknowledges the challenge of connecting with adolescent children, and provides specific tips on how to do this | Sound research evidence that parental “warmth” is protective against both anxiety and depression; endorsed by experts |
Be involved and support increasing autonomy | Your involvement in your teenager’s life | Nurture roots and inspire wings | Helps parents establish the important balance between staying involved and interested in their adolescent’s life, while encouraging increasing age-appropriate autonomy | Sound research evidence that overinvolvement is a risk factor for depression, and autonomy granting and monitoring are protective factors; endorsed by experts |
Encourage supportive relationships | Your teenager’s relationships with others | Good friends, supportive relationships | Provides strategies for parents to support their adolescent’s social skills development | Emerging evidence of parental encouragement of sociability is associated with less adolescent anxiety; endorsed by experts |
Establish family rules and consequences | Your family rules | Raising good kids into great adults: establishing family rules | Highlights the importance of consistent and clear boundaries for adolescent behaviors, and provides specific strategies to establish these | Emerging evidence of the association between inconsistent discipline and depression; endorsed by experts |
Minimize conflict in the home | Your home environment | Calm versus conflict | Addresses the need for adaptive conflict management between parents and between parent and adolescent, and provides specific strategies to do these | Sound evidence that interparental conflict and aversiveness (including parent-adolescent conflict) are risk factors for both depression and anxiety; endorsed by experts |
Encourage good health habits | Health habits | Good health habits for good mental health | Provides strategies to help parents encourage good health habits in their adolescent, including a healthy diet, physical activity, good sleep habits, and abstinence from alcohol and drugs | Endorsed by experts; evidence that these health habits are associated with risk for depression and anxiety |
Help your teenager to deal with problems | Dealing with problems in your teenager’s life | Partners in problem solving | Provides strategies for parents to help their adolescent develop good problem solving and stress management skills | Endorsed by experts |
Help your teenager to deal with anxiety | Coping with anxiety | From surviving to thriving: helping your teenager deal with anxiety | Provides strategies for parents to help their adolescent manage their everyday anxiety | Sound evidence that overprotective, anxious parenting is associated with both anxiety and depression in adolescents; endorsed by experts |
Encourage professional help seeking when needed | Getting help when needed | When things aren’t okay: getting professional help | Helps parents understand what depression and anxiety problems can look like in adolescents, and what they can do if their adolescent is or becomes unwell | Endorsed by experts; evidence that parents are important conduits to young people seeking professional help for mental health problems |
Don’t blame yourself | Don’t blame yourself (not included in parenting scale, included in feedback report for all parents) | N/A; No module on this topic | Aims to dispel guilt or self-blame in parents | Endorsed by experts |
aN/A: not applicable.
Finally, to ensure that the suggested strategies recommended to parents in the intervention were acceptable and relevant to adolescents, we consulted with two focus groups of adolescents in the age range of 12 to 15 years. Adolescents were recruited through two local schools that differed on ethnic and sociodemographic characteristics, and focus group consultations were conducted in school classrooms. Consulting with adolescents of different ages and in different schools enabled us to capture some developmental, ethnic, and sociodemographic variations in adolescent views. Adolescents were presented with some of the parenting strategies recommended for parents in PIP (eg, show interest in your adolescent’s life and spend regular one-on-one time together) and provided feedback about some ways in which the strategies could be implemented in an acceptable way with contemporary adolescents. Adolescents provided specific ideas and suggestions that were incorporated into the content of various modules, including activities they enjoy doing with their parents and ways their parents could show them affection. These consultations also informed the scripts for adolescent audio clips included in some modules, where adolescents talked about topical issues such as how they feel when their parents argue, and how parents could help when they (the adolescents) get “stressed out.”
The PIP intervention development was completed in May 2015. We are evaluating the effects of the intervention via two randomized controlled trials (RCTs) that have been registered with the Australian New Zealand Clinical Trials Registry (Trial IDs ACTRN12615000247572 and ACTRN12615000328572).
The PIP intervention was designed for implementation as a multi-level public health intervention to empower parents to support their child’s mental health across all levels of the mental health intervention continuum [
Level 1 is the minimal intervention and constitutes a general parent-education initiative across the community. Parents can choose to consider and apply any of the Guidelines’ recommendations as and when they deem fit. Given the evidence base [
Each subsequent level in the model represents increasing intensity of support and intervention for parents. Level 2 requires parents to first complete a self-assessment parenting scale (the PRADAS) to receive their personalized feedback report. This level is likely to suit a similar group of parents as level 1 but who prefer a tailored approach. Level 2 can also serve as a prompt for some parents to take further action, if required, to seek further support to improve their parenting practices. Parents with lower parental self-efficacy may find the level of support provided by a once-off brief intervention such as the feedback report insufficient and thus, be prompted to complete the interactive Web-based program (next level up) and/or seek other resources or services including mental health services for themselves and/or their child. To facilitate this, the feedback report includes links to other online resources, including an online screening tool (the Strengths and Difficulties Questionnaire; [
At level 3, parents receive both the tailored feedback report and are recommended specific modules to provide additional support to implement the strategies highlighted in their feedback report. Drawing heavily from PSD principles, the intervention is designed to maximize adherence as a self-guided program [
A multi-level public health approach to support parents.
However, a recent review (Finan SJ et al, 2017, unpublished data) found that although higher child mental health symptoms may be associated with initial engagement (eg, enrolment) in preventive parenting programs, this does not increase attendance or reduce the likelihood of parents dropping out of programs [
At level 4, parents receive not only all components of the PIP Web-based intervention but also the support of a trained therapist to coach them in implementing the strategies recommended in the PIP program. According to the Health Belief Model [
Within the proposed model, stepping up is based on one or both of the following criteria: (1) automated recommendation of the tailored program based on parents’ responses to a self-assessment of their current parenting (parenting competencies as assessed by the PRADAS), parental self-efficacy, or their child’s current symptoms and/or (2) parents’ personal preference, which can override the program’s recommendation. Referral to other evidence-based, more intensive parenting programs can occur at any point throughout the model for parents who want programs with a different delivery mode, increased support (therapist or nontherapist), or a specific focus (eg, emotion coaching). Parents whose personal mental health and/or other difficulties hinder them from engaging with and benefitting from the Web-based program will be referred to other mental health services for themselves. Parents who raise significant concerns about their child’s behavior and mental health will also be referred to additional services to better support their child (parents can still continue to use the PIP program if they wish).
In this paper, we have described a new approach to developing a Web-based intervention that rigorously translates research evidence into intervention strategies and aligns with more established development models from the parenting program [
An important consideration for the proposed multi-level approach is the source of funding to sustain it. Given that the Web-based intervention is fully developed and evaluated, it is in itself relatively inexpensive to maintain, except when substantial updates and improvements are required. However, where personnel are involved, for either administrative or therapeutic or coaching support, substantial costs will be incurred if the program is implemented at scale. Possible funding models include a user-pays business model, an advertising-based revenue model, or government or third-sector funding. As an international leader in e-mental health [
To maximize its uptake and sustainability, the program needs to be integrated into existing public health and health care systems [
Research on parent preferences for information on child mental health, in the context of seeking treatment services for their child, also highlights the importance of considering specific preferences of different subgroups [
Parents have an important role in reducing the risk and impact of adolescent internalizing disorders, but there is a lack of evidence-based, cost-effective programs to equip parents for this role. This paper described the development of the PIP Web-based intervention and proposed a public health approach that utilizes this intervention at varying levels of intensity to support parents. Evaluation of each separate level of the model is ongoing. Further evaluation of the whole approach is required to assess the utility of the intervention as a public health approach, and its effects not just on parenting competencies, parental self-efficacy, and adolescent depression and anxiety outcomes, but also broader functioning (eg, school engagement, general health, quality of life, and peer relationships), and socioeconomic outcomes.
Screenshots of the Partners in Parenting intervention.
Persuasive systems design (PSD) principles fulfilled in the Partners in Parenting (PIP) intervention.
cognitive behavioral therapy
Center for eHealth Research
electronic health
Partners in Parenting
Persuasive Systems Design
Parenting to Reduce Adolescent Depression and Anxiety Scale
randomized controlled trial
The authors acknowledge funding from the National Health and Medical Research Council (NHMRC) for the Web development of the PIP intervention and the partnership of
None declared.