Children impacted by caregiver substance use disorder (SUD) have been largely ignored in the public health response to the opioid epidemic despite their very high risk for spiraling toward pathways to their own SUD. Parent education and support programs have a long track record of reducing risks for this vulnerable population. Triple P, in particular, is a well-established preventative approach that has repeatedly demonstrated the largest intervention effects on both substance-involved parent and child outcomes when compared to other intervention types (e.g., school- or community-based). However, barriers to implementation persist in the ability to engage parents in Triple P and other parenting programs, which has been a limiting factor in achieving their full benefits and scaling these types of interventions. A solution to the problem is to transform Triple P, one of the most effective parenting programs ever developed, into a smart phone game application to increase its acceptability, relevance and accessibility for even the most difficult to reach caregivers.

 

This highly innovative approach will integrate the Triple P curriculum and a gaming application to produce a cutting-edge content delivery system that has shown great promise for preventive interventions. Traditional approaches to delivering parent education include support programs in-person, either individually in the home or in group-based formats, as well as online versions. These traditional solutions require commitments of large chunks of time on the part of parents, typically one to two hours at a time, not including travel when in-person, plus the hassle and expense of sitters for their children. While these traditional solutions have been successful with some caregivers with SUDs, challenges persist with wide scale dissemination of these programs to this particular population outside of the research setting. Our solution will increase knowledge, instill parenting and coping skills and improve child outcomes in a highly interactive format in short five to ten minute segments that can easily be completed throughout a caregiver’s daily routine; for example, while waiting in line, for an appointment or to pick up children, during commutes on public transportation, or otherwise during momentary downtimes. We will develop an engaging interactive and enjoyable platform.

 

The parenting intervention that will be converted is Triple P, which has an evidence base consisting of approximately 116 empirical studies conducted over the course of 33 years. A meta-analysis of 101 quantitative research studies involving 16,099 families confirmed that the program had positive impacts on parenting practices and children’s social, emotional and behavioral outcomes (Sanders, Kirby, Tellegen & Day, 2014). An eight-module web-based version of Triple P demonstrated impacts comparable to in-person Triple P interventions demonstrating that the program can be effective when delivered in a self-paced, digital format (Prinz, Metzler, Sanders, Rusby & Cai, 2021; Sanders, Baker & Turner, 2012). An enhanced version of the web-based program was developed with basic gaming features—specifically an online avatar that participants could use to interact anonymously with other users on social media and badges to reward progress through the program. A study of this program demonstrated promising results and high levels of satisfaction with a very high-risk families; 38% of parents were receiving SUD treatment and 41% had a history of incarceration (Love, Sanders, Turner, Maurange, Knott, Prinz, Metzler & Ainsworth, 2016).

 

Preventive intervention games have been more widely used with children and adolescents than adults (see a recent review by Zayeni, Raynaud, & Revet, 2020), and not with adults influential in their lives. Examples include smoking or vaping prevention (Weser et al., 2021; though see Guillory et al., 2020, for a study with adults), sexual health literacy and abuse prevention (Fiellen et al., 2017; Jones et al., 2020), self esteem (de la Barrera et al., 2021), and social skills awareness (DeRosier & Thomas, 2019; Hubal et al., 2008). And there have been specialized serious games for adults, such as in exposure therapy (Tavabi et al., 2020) or binge drinking prevention (Hong, Cabrera, & Beaudoin, 2020). However, to our knowledge, no evidence-based parenting intervention has been delivered entirely in a gaming format.

 

The approach is equally appropriate for and attractive to adults. A national study conducted by the Mobile Marketing Association found that 86% of people who play mobile games are age 25 and above, and that 70% of women report playing mobile games (https://www.mmaglobal.com/research/myth-busting-mobile-gaming-demographics). According to the Mobile Marketing Association, the popularity of mobile games can be attributed in part to the near universal use of smart phones and the introduction of games to audiences that do not own gaming consoles. Smart phones are a particularly accessible technology with 81% of adults in the US reporting that they own a smart phone and roughly 25% of low income, Latinx and African American adults reporting that their smart phone is their only connection to the internet (https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home-broadband-2019/). Providing high-quality parenting support using smart phones has the potential to significantly increase availability of these programs and their attractiveness to traditionally difficult-to-serve populations.

 

Extending beyond rewards and feedback used in previous approaches, the actual engagement of participants in simulated situations has been demonstrated to be an effective prevention and intervention platform. Features built into this project will increase both its efficacy and attractiveness. The app will use an incentive structure that builds in rewards for different aspects of play to increase game use and reinforce learning of program components. Another highly innovative and novel aspect of this solution will be the embedding of knowledge from the field of neuroscience about the neurocognitive processes likely being engaged when parents practice skills designed to strengthen cognitive control over emotional responses in their children (for example, a strong parent-child attachment has been associated with activity in neural circuitry underlying empathy, motivation, and self-regulation of behavior). This information will be translated into readily accessible language and initiated by a brain icon (for example) that pops up and when clicked, indicating to the caregiver how the child’s brain may be responding to that action (e.g., affection, bonding, authoritative parentings, etc.).

 

The ubiquitous use of smart phones even by underserved populations and the success of cell phone gaming apps among adults indicates that converting the notably effective Triple P intervention into a smart phone gaming app has great promise. Increasing access to and uptake of evidence-based parenting strategies in caregivers who are notoriously difficult to reach with traditional preventive interventions through a fun, easily digestible and inherently engaging platform like cell phone game apps has potential to more broadly improve child outcomes and reinforce recovery in the caregiver.