Perspectives on Caregiver-Focused mHealth Technologies to Improve Mental Health Treatment for Low-Income Youth with ADHD

  • Janet R. CummingsEmail author
  • Laura M. Gaydos
  • Augustina Mensa-Kwao
  • Minna Song
  • Sarah C. Blake


To examine stakeholder perspectives regarding (1) whether mobile health (mHealth) tools can improve the mental health (MH) treatment process for low-income youth with ADHD in safety net settings and (2) what functions would be helpful to improve the treatment process. This study analyzed qualitative data from a larger project that collected information from key stakeholders at four safety net clinics across Georgia. We conducted five focus groups with caregivers who had a Medicaid-insured child receiving treatment for ADHD, and 17 semi-structured interviews with clinic administrators and providers. Stakeholders shared their perspectives on strategies to improve the MH treatment process, including the use of mHealth tools. Caregivers also completed a brief survey about technology use. We present findings from a thematic analysis of the qualitative data and descriptive findings from the survey. Participants in each group of stakeholders expressed interest in mHealth tools that would (1) deliver reminders for caregivers (including appointment and medication refill reminders); (2) help caregivers obtain information about ADHD symptoms and treatment options; (3) help caregivers track information about their child’s symptoms and treatment progress; and (4) facilitate communication between caregivers and providers. While more than three-fourths of caregivers had a smartphone, providers and administrators expressed concern that access to mHealth technologies may be inconsistent if low-income families are unable to pay cellular phone bills. Caregivers, clinic administrators, and providers were supportive of enhanced mHealth technologies to improve MH care for this population.


mHealth Mental health services Children Safety net providers 


Funding Information

This work was supported by the National Institute of Mental Health (K01MH095823). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Following the explanation of the general study purpose, each participant provided written (caregivers) or verbal (provider and administrators) consent, which assured the voluntary nature of participation, the confidentiality of responses, and the right to end the interview at any time or refrain from answering questions. This study received IRB approval through Emory University’s Institutional Review Board.

Conflict of Interest

The authors declare that they have no conflicts of interest.


  1. Aguilera, A., & Muñoz, R. F. (2011). Text messaging as an adjunct to CBT in low-income populations: a usability and feasibility pilot study. Professional Psychology: Research and Practice, 42(6), 472–478.CrossRefGoogle Scholar
  2. Archangeli, C., Marti, F. A., Wobga-Pasiah, E. A., & Zima, B. (2017). Mobile health interventions for psychiatric conditions in children: a scoping review. Child and Adolescent Psychiatric Clinics of North America, 26(1), 13–31.CrossRefGoogle Scholar
  3. Berrouiguet, S., Baca-Garcia, E., Brandt, S., Walter, M., & Courtet, P. (2016). Fundamentals for future mobile-health (mHealth): a systematic review of mobile phone and web-based text messaging in mental health. Journal of Medical Internet Research, 18(6), e135.CrossRefGoogle Scholar
  4. Branson, C. E., Clemmey, P., & Mukherjee, P. (2013). Text message reminders to improve outpatient therapy attendance among adolescents: a pilot study. Psychological Services, 10(3), 298–303.CrossRefGoogle Scholar
  5. Bussing, R., Narwaney, K. J., Winterstein, A. G., Newton, D. A., DeBar, L., Boscarino, J. A., Toh, S., Pawloski, P., Nordin, J. D., Herrinton, L. J., Mason, D., & Daley, M. F. (2014). Pharmacotherapy for incident attention-deficit/hyperactivity disorder: practice patterns and quality metrics. Current Medical Research and Opinion., 30(8), 1687–1699.CrossRefGoogle Scholar
  6. Costello, E. J., He, J.-P., Sampson, N. A., Kessler, R. C., & Merikangas, K. R. (2014). Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatric Services, 65(3), 359–366.CrossRefGoogle Scholar
  7. Cummings, J. R. (2014). Contextual socioeconomic status and mental health counseling use among US adolescents with depression. Journal of Youth and Adolescence, 43(7), 1151–1162.CrossRefGoogle Scholar
  8. Cummings, J. R., Wen, H., Ko, M., & Druss, B. G. (2013). Geography and the Medicaid mental health care infrastructure: implications for health care reform. JAMA Psychiatry, 70(10), 1084–1090.CrossRefGoogle Scholar
  9. Cummings, J., Case, B., Ji, X., & Marcus, S. (2016). Availability of youth services in U.S. mental health treatment facilities. Administration and Policy in Mental Health and Mental Health Services Research, 43(5), 717–727.CrossRefGoogle Scholar
  10. Cummings, J. R., Allen, L., Clennon, J., Ji, X., & Druss, B. G. (2017a). Geographic access to specialty mental health care across high- and low-income US communities. JAMA Psychiatry, 74(5), 476–484.CrossRefGoogle Scholar
  11. Cummings, J. R., Ji, X., Allen, L., Lally, C., & Druss, B. G. (2017b). Racial and ethnic differences in ADHD treatment quality among Medicaid-enrolled youth. Pediatrics, 139(6).Google Scholar
  12. DosReis, S., Mychailyszyn, M. P., Evans-Lacko, S. E., Beltran, A., Riley, A. W., & Myers, M. A. (2009). The meaning of attention-deficit/hyperactivity disorder medication and parents' initiation and continuity of treatment for their child. Journal of Child and Adolescent Psychopharmacology., 19(4), 377–383.CrossRefGoogle Scholar
  13. Evans, G. W., & Cassells, R. C. (2014). Childhood poverty, cumulative risk exposure, and mental health in emerging adults. Clinical Psychological Science., 2(3), 287–296.CrossRefGoogle Scholar
  14. Fontanella, C. A., Bridge, J. A., Marcus, S. C., & Campo, J. V. (2011). Factors associated with antidepressant adherence for Medicaid-enrolled children and adolescents. Annals of Pharmacotherapy, 45(7–8), 898–909.CrossRefGoogle Scholar
  15. Gopalan, G., Goldstein, L., Klingenstein, K., Sicher, C., Blake, C., & McKay, M. M. (2010). Engaging families into child mental health treatment: updates and special considerations. Journal of the Canadian Academy of Child and Adolescent Psychiatry., 19(3), 182–196.Google Scholar
  16. Guest, G., & MacQueen, K. M. (2008). Handbook for team-based qualitative research. Lanham: AltaMira Press.Google Scholar
  17. Hamine, S., Gerth-Guyette, E., Faulx, D., Green, B. B., & Ginsburg, A. S. (2015). Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. Journal of Medical Internet Research, 17(2), e52.CrossRefGoogle Scholar
  18. Harrison, M., McKay, M., & Bannon, W. (2004). Inner-city child mental health service use: the real question is why youth and families do not use services. Community Mental Health Journal., 40(2), 119–131.CrossRefGoogle Scholar
  19. Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.CrossRefGoogle Scholar
  20. Kannisto, K. A., Adams, C. E., Koivunen, M., Katajisto, J., & Valimaki, M. (2015). Feedback on SMS reminders to encourage adherence among patients taking antipsychotic medication: a cross-sectional survey nested within a randomised trial. BMJ Open, 5(11), e008574.CrossRefGoogle Scholar
  21. Kauer, S. D., Reid, S. C., Sanci, L., & Patton, G. C. (2009). Investigating the utility of mobile phones for collecting data about adolescent alcohol use and related mood, stress and coping behaviours: lessons and recommendations. Drug and Alcohol Review, 28(1), 25–30.CrossRefGoogle Scholar
  22. Khoja, S., Khan, M. A., Husyin, N., Scott, R., Yousafzai, A. W., Durrani, H., Mohbatali, F., & Khan, D. (2015). Improving mental health care for young adults in Badakshan Province of Afghanistan using eHealth. Studies in Health Technology and Informatics, 209, 46–50.Google Scholar
  23. Kunigiri, G., Gajebasia, N., & Sallah, D. (2014). Improving attendance in psychiatric outpatient clinics by using reminders. Journal of Telemedicine and Telecare, 20(8), 464–467.CrossRefGoogle Scholar
  24. Lewin, M. E., & Altman, S. (Eds.). (2000). America’s health care safety net: intact but endangered. Washington D.C.: Institute of Medicine. National Academy Press.Google Scholar
  25. Luxton, D. D., McCann, R. A., Bush, N. E., Mishkind, M. C., & Reger, G. M. (2011). mHealth for mental health: integrating smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice, 42(6), 505–512.CrossRefGoogle Scholar
  26. Mann, C., Rowland, D., & Garfield, R. (2003). Historical overview of children’s health care coverage. Future of Children, 13(1), 31–53.CrossRefGoogle Scholar
  27. Matthews, M., Doherty, G., Sharry, J., & Fitzpatrick, C. (2008). Mobile phone mood charting for adolescents. British Journal of Guidance and Counselling, 36(2), 113–129.CrossRefGoogle Scholar
  28. MAXQDA. (2007). MAXQDA: the art of text analysis [computer program]. Sozialforschung GmbH Germany: Marburg VERBI Software Consult.Google Scholar
  29. Merikangas, K. R., He, J.-P., Brody, D., Fisher, P. W., Bourdon, K., & Koretz, D. S. (2010a). Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics, 125(1), 75–81.CrossRefGoogle Scholar
  30. Merikangas, K. R., He, J.-P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010b). Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 980–989.CrossRefGoogle Scholar
  31. National Academies of Sciences, Engineering, and Medicine. (2015). Mental disorders and disabilities among low-income children (pp. 1–472). Washington, DC: The National Academies Press.Google Scholar
  32. National Alliance on Mental Illness. (2016). Engagement: a new standard for mental health care. Arlington.Google Scholar
  33. O’Cathain, A., Murphy, E., & Nicholl, J. (2010). Three techniques for integrating data in mixed methods studies. BMJ, 341(7783).Google Scholar
  34. Olff, M. (2015). Mobile mental health: a challenging research agenda. European Journal of Psychotraumatology, 6, 27882.CrossRefGoogle Scholar
  35. Park, E., Kim, H., & Steinhoff, A. (2016). Health-related internet use by informal caregivers of children and adolescents: an integrative literature review. Journal of Medical Internet Research, 18(3), e57.Google Scholar
  36. Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks: Sage Publications.Google Scholar
  37. Pew Research Center. (2015). U.S. smartphone use in 2015. Accessed 10 Jan 2018.
  38. Reardon, T., Harvey, K., Baranowska, M., O’Brien, D., Smith, L., & Creswell, C. (2017). What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. European Child & Adolescent Psychiatry, 26(6), 623–647.CrossRefGoogle Scholar
  39. Richardson, L., Digiuseppe, D., Christakis, D., McCauley, E., & Katon, W. (2004). Quality of care for Medicaid-covered youth treated with antidepressant therapy. Archives of General Psychiatry, 61(5), 475–480.CrossRefGoogle Scholar
  40. Sheoran, B., Silva, C. L., Lykens, J. E., Gamedze, L., Williams, S., Ford, J. V. N., & Habel, M. A. (2016). YTH StreetConnect: development and usability of a mobile app for homeless and unstably housed youth. JMIR Mhealth and Uhealth, 4(3), e82.CrossRefGoogle Scholar
  41. Shoffner, J., Staudt, M., Marcus, S., & Kapp, S. (2007). Using telephone reminders to increase attendance at psychiatric appointments: findings of a pilot study in rural Appalachia. Psychiatric Services, 58(6), 872–875.CrossRefGoogle Scholar
  42. Sims, H., Sanghara, H., Hayes, D., Wandiembe, S., Finch, M., Jakobsen, H., Tsakanikos, E., Okocha, C. I., & Kravariti, E. (2012). Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatric Services, 63(2), 161–168.CrossRefGoogle Scholar
  43. Stagman, S., & Cooper, J. L. (2010). Children’s MH: what every policymaker should know. Accessed 2 Jan 2018.
  44. Statistical Enrollment Data System (SEDS). (2017). Combined CHIP Enrollment Total Report and Form CMS-64.EC. Accessed 2 Jan 2018.
  45. Stein, B. D., Klein, G. R., Greenhouse, J. B., & Kogan, J. N. (2012). Treatment of attention-deficit hyperactivity disorder: patterns of evolving care during the first treatment episode. Psychiatric Services, 63(2), 122–129.CrossRefGoogle Scholar
  46. Syed, S., Gerber, B. S., & Sharp, L. (2013). Traveling towards disease: transportation barriers to health care access. Journal of Community Health, 38, 976–993.CrossRefGoogle Scholar
  47. World Health Organization. (2011). mHealth: new horizon for health through mobile technologies: based on the findings of the second global survery on eHealth. Global Observatory for eHealth series – Volume 3. Geneva, Switzerland. Accessed 15 Jan 2018.
  48. Zima, B. T., Hurlburt, M. S., Knapp, P., Ladd, H., Tang, L., Duan, N., Wallace, P., Rosenblatt, A., Landsverk, J., & Wells, K. B. (2005). Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California. Journal of the American Academy of Child and Adolescent Psychiatry, 44(2), 130–144.CrossRefGoogle Scholar
  49. Zima, B. T., Bussing, R., Tang, L., et al. (2010). Quality of care for childhood attention deficit/hyperactivity disorder in a managed care Medicaid program. Journal of the American Academy of Child and Adolescent Psychiatry, 49(12), 1225–123811.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Health Policy and Management, Rollins School of Public HealthEmory UniversityAtlantaUSA
  2. 2.Department of Behavioral Health Sciences and Health Education, Rollins School of Public HealthEmory UniversityAtlantaUSA

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