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Open AccessResearch Report

Res@t: Resource-Strengthening Training for Adolescents with Problematic Digital-Media Use and their Parents

Published Online:April 13, 2023https://doi.org/10.1024/0939-5911/a000810

Abstract

Abstract:Aims: Given rising prevalence of digital-media related disorders (DMRD, i. e. the problematic use of digital games, social media, and streaming platforms) in children and adolescents, the new therapy program Res@t (Resource strengthening program for adolescents with DMRD and their parents) aims to close a significant evidence-based treatment gap. It addresses affected adolescents and their parents in different settings. Methods: Res@t is a fully manualized CBT program based on current research results and clinical experiences. It was initially developed for adolescents with problematic gaming (Res@t-A) and their parents (Res@t-P) in a face-to-face group setting. A digital translation into a fully automated application (Res@t digital [Res@pp]) should allow support independently of available local therapy options or the use within blended therapy. Besides DMRD symptom reduction in adolescents through Res@t-A, Res@t-P shall increase parental self-efficacy. Pilot-study data of Res@t-P within a pre-post-follow-up design showed promising effects on a decrease of parental stress perception and an increase of family functioning, as well as on DMRD symptom reduction in affected adolescents. However, a missing control group and rather small sample size reduces interpretability. Res@t-A is currently being evaluated within a comparable design. Multi-center randomized controlled studies are planned to evaluate the effectiveness of all offline and digital program versions. Conclusion: Res@t is the first manualized treatment program focusing on adolescents with DMRD and their parents for different settings (group therapy, digital application). Effective treatments addressing both target groups are highly warranted.

Ressourcenstärkendes Training für Adoleszente mit problematischem Mediengebrauch und deren Eltern

Zusammenfassung:Ziele: Vor dem Hintergrund einer steigenden Prävalenz von medienbezogenen Störungen (MBS, problematische Nutzung digitaler Spiele, sozialer Medien und Streamingdienste) bei Kindern und Jugendlichen zielt das neue Therapieprogramm Res@t (Ressourcenstärkendes Training für Adoleszente mit MBS und deren Eltern) darauf ab, eine bedeutende evidenzbasierte Behandlungslücke zu schließen. Es richtet sich an betroffene Adoleszente und ihre Eltern in verschiedenen Settings. Methoden: Res@t ist ein vollständig manualiertes, KVT-basiertes Behandlungsprogramm, das auf aktuellen Forschungsergebnissen und klinischen Erfahrungen beruht. Es wurde zunächst für Adoleszente mit problematischem Computerspielverhalten (Res@t-A) und deren Eltern (Res@t-P) im Rahmen zweier Gruppeninterventionen entwickelt. Eine digitale Übersetzung beider Trainings in eine vollautomatische App (Res@t digital [Res@pp]) soll die Unterstützung von Betroffenen unabhängig von verfügbaren lokalen Behandlungsmöglichkeiten oder den begleitenden Einsatz in einer laufenden Behandlung ermöglichen. Neben der MBS-Symptomreduktion bei Kindern und Jugendlichen durch Res@t-A, soll Res@t-P die elterliche Selbstwirksamkeit erhöhen. Pilotstudiendaten von Res@t-P im Rahmen eines Prä-Post-Follow-up-Designs zeigten vielversprechende Effekte auf eine Abnahme elterlichen Stressempfindens und auf eine Steigerung der Familienfunktionalität sowie auf die MBS-Symptomreduktion betroffener Adoleszente. Das Fehlen einer Kontrollgruppe und die relativ kleine Stichprobengröße schränken die Interpretierbarkeit der Ergebnisse jedoch ein. Res@t-A wird derzeit im Rahmen einer eigenständigen Pilotstudie mit einem vergleichbaren Design an drei universitären Standorten evaluiert. Hier zeigt sich eine gute Programmakzeptanz bei den Teilnehmenden. Darüber hinaus sind multizentrische randomisiert-kontrollierte Studien geplant, um die Wirksamkeit beider Offline-Programme und der digitalen Intervention zu evaluieren. Schlussfolgerung: Res@t ist das erste manualisierte Behandlungsprogramm, das sich auf Adoleszente mit MBS und ihre Eltern in verschiedenen Settings (Gruppentherapie, digitale App) konzentriert. Wirksame Behandlungen, die sich an beide Zielgruppen richten, sind bislang rar und werden dringend benötigt.

Introduction

The majority of German children and adolescents use digital media on a frequent level: 93 % of the 12- to 19-year olds own a smartphone and use social media (92 %), streaming platforms (90 %) and digital games (68 %) at least several days a week (Feierabend et al., 2021). Given their higher vulnerability to develop mental disorders including addictions (Kessler et al., 2005), a regular media use might turn into problematic patterns for some adolescents.

Conceptualization

The problematic use of digital media has been of rising scientific and clinical interest during the past two decades. Based on the criteria of substance-use and gambling disorders the American Psychiatric Association (APA) offered an operationalization of problematic gaming as the first behavioral addiction solely associated with digital media in the appendix of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013 (American Psychiatric Association, 2013). Therein, Internet Gaming Disorder (IGD) was included as a condition that requires further research. It is described as an excessive use of digital games, online or offline, that concludes in significant impairments of quality of life.

In 2018 the World Health Organization (WHO) announced the inclusion of Gaming Disorder (GD) as an official diagnosis in its eleventh edition of the International Classification of Diseases and Related Health Problems (ICD) under the umbrella of behavioral addictions (World Health Organisation, 2022). Here, GD is characterized by a pattern of persistent or recurrent gaming behavior that can occur online or offline. In addition, the ICD-11 lists the term Hazardous Gaming (HD) as a problem “associated with health behaviors” which can be used to describe gaming behavior not yet being pathological but posing an increased health risk. Innately, the behavior is maintained despite the awareness of the increased risk to self or others. Both gaming patterns can be subsumed under the term Problematic Gaming (PG).

In research and clinical practice, the diagnostic criteria for (I)GD have been translated to related disorders associated with digital media use (digital media-related disorders, DMRD). Based on the statistics on usage frequencies in children and adolescents, in addition to GD, the most relevant in this age group are the pathological use of social media (Social Media Use Disorder, SMUD) and streaming services (Streaming Disorder, SD). Comparable standardized questionnaires applying the ICD-11 criteria to the three DMRD are now available in self- and parental report (Gaming Disorder Scale for Adolescents, GADIS-A; Paschke et al., 2020; Gaming Disorder Scale for Parents, GADIS-P; Paschke et al., 2021a, Social Media Disorder Scale for Adolescents, SOMEDIS-A; Paschke et al., 2021b; Social Media Disorder Scale for Parents, SOMEDIS-P; Paschke, Austermann, et al., 2022; Streaming Disorder Scale for Adolescents, STREDIS-A; Paschke, Napp et al., 2022; Streaming Disorder Scale for Parents, STREDIS-P; Paschke et al., 2023).

Prevalence

A recent meta analysis estimates the global prevalence rates for PG at about 3 % whereas the prevalence for adolescents is shown to be highest (Stevens et al., 2021). Prevalence for SMUD are estimated at about 3 % (Paschke et al., 2021b) and for SD at about 4 % for German 10- to 17-year olds (Paschke, Napp et al., 2022). An increase in usage times and prevalence rates was observed under the COVID-19 pandemic (DAK-Gesundheit, 2021; Paschke, Austermann, Simon-Kutscher et al., 2021).

Comorbidities

DMRD in childhood and adolescence are usually accompanied by mental comorbidities including attention deficit hyperactivity disorder (ADHD), depression, (social) anxiety, obsessive-compulsive, somatization, autism-spectrum, and sleeping disorders (Coutelle et al., 2021; Dullur et al., 2021; González-Bueso et al., 2018; Hussain et al., 2012; Männikkö et al., 2020; Ostinelli et al., 2021; Paschke, Sack et al., 2021; Piteo & Ward, 2020; Pluhar et al., 2019). In addition, oppositional-defiant and conduct disorders, problems with anger control (Wartberg, Moll et al., 2017), greater difficulties in emotion regulation, procrastination, and avoidance (Kökönyei et al., 2019; Uçur & Dönmez, 2021; Wartberg et al., 2021), deficits in social skills and problems in contact with peers (Paulus et al., 2018; Sugaya et al., 2019), as well as reduced sleep quality (Lange et al., 2017) have been shown to be associated with DMRD.

Etiology

Different models describe the etiology of DMRD, such as the integrative process model of Internet addiction (Müller & Wölfling, 2017) and the I-PACE model of specific Internet addiction (Brand et al., 2019). The triad model of addiction (Kielholz & Ladewig, 1973) assumes a complex interaction of media-related, personal, and social factors. Based on this biopsychosocial approach, learning theories (conditioning, observational and cognitive learning), as well as knowledge about stress management (diathesis-stress model; Lazarus, 1974), and information processing are used to illustrate the self-sustaining dynamics of DMRD. In more detail, media-related factors refer to characteristics of digital applications developed to increase user bonding. For further reading, see Rumpf (2017). Moreover, personal factors include personality traits such as high levels of neuroticism, sensation seeking, and a low expression on the personality trait conscientiousness (Hu et al., 2017; Sussman et al., 2018; Wang et al., 2013). In adolescence, significant neural remodeling processes occur and the span between a fully-developed reward and an immature cognitive control system is greatest leading to a higher susceptible to addictive behaviors (Casey & Jones, 2010). This physiological gap seems to be larger in adolescents with PG (Schettler et al., 2022). In addition, deficits in executive functions are found in affected individuals, regardless of age, gender, geographic region, and type of media use, as well as an increased experience of stress (Ioannidis et al., 2019). Finally, social factors include mental health and stress experiences of parents, parental media use and role modeling, family factors, such as intrafamily conflict, invalidating communication, difficulties in the parent-child relationship, and low family functioning, peer relationships and cultural factors are significantly associated with DMRD in adolescents (Donati et al., 2021; Lam, 2020; Paakkari et al., 2021; Schneider et al., 2017; Wartberg, Kriston et al., 2017).

Treatments

Treatment options for adolescents with PG and other DMRD are still limited and intervention studies vastly differ in their quality due to their heterogeneity in study design or methodological issues (e. g., small sample sizes, absent control group; Zajac et al., 2020). Nevertheless, studies on therapeutical group or individual interventions for adolescents with PG suggest cognitive-behavioral therapy (CBT) to be most effective (Gioia & Boursier, 2019; King et al., 2017). Further evidence was found for the pharmacological therapy of comorbidities, the application of virtual realties, and family-oriented interventions (Park et al., 2016; Stevens et al., 2019).

While recent studies proclaim the necessity of family-oriented interventions (Bonnaire & Phan, 2017; Lampropoulou et al., 2022), this approach has been only accounted for in a small number of programs (e. g., Torres-Rodríguez et al., 2018). Currently, parents are scarcely involved in the treatment of PG in adolescents or involvement is reduced to psychoeducation (González-Bueso et al., 2018). A combination of individual and family therapy seems to have a significant positive effect on PG symptom reduction, although superiority over classical CBT could not be consistently shown (González-Bueso et al., 2018; Torres-Rodríguez et al., 2018). However, Nielsen et al. (2021) found the multidimensional approach of including individual, parental, family, and environmental factors in the treatment of PG to be superior over a classical family therapy approach. Therefore, it is clinical consensus to address parents of affected adolescents directly and incorporate topics like parental needs, parental mental health, parenting behavior and distress associated with their child’s problematic media usage in the treatment of DMRD (Bonnaire et al., 2019; Brandhorst et al., 2022; Donati et al., 2021; Geurts et al., 2022; Wendt et al., 2021).

The Res@t Program

Development

Res@t has been initially developed as a psychotherapeutical group-treatment program for adolescents with PG and their parents by clinical and scientific experts (child and adolescent psychiatrists and psychotherapists) in the field of behavioral addictions. The name of this fully manualized treatment program stands for “Resource-Strengthening Training for Adolescents with Problematic Gaming and their Parents”. Content and realization are based on up-to-date scientific and clinical knowledge on DMRD complemented by clinical experiences, and the results of qualitative interviews with affected adolescent patients and clinical experts (Wendt et al., 2021). Moreover, a focus group with six parents of adolescents with PG was performed on program content and setting as well as parental individual and group needs. During an initial program run a qualitative participant feedback on satisfaction, acceptance, and suggestions for improvement was collected after every module and the completed training. Consequently, minor program adjustments were made where appropriate.

Aims

The intervention has been subdivided into two separate trainings: a targeted group training for adolescents (Res@t-A) and a targeted group training for parents (Res@t-P) which can be run independently and focus on the strengthening of resources to reduce PG patterns, improve well-being, increase self-efficacy and self-control, support parenting skills and family functioning, and reduce adolescent as well as parental stress.

In line with the empirical evidence, treatment techniques are based on CBT including psychoeducation, behavioral analyses and self-monitoring, but also incorporate aspects of motivational interviewing (MI), dialectic behavioural therapy (DBT) and mindfulness-based stress reduction (MBSR). All techniques have been adapted for the developmental specifications of the adolescent age span.

Administration

Although both trainings can be run separately, ideally, Res@t-A and Res@t-P should be administered in parallel for optimal therapeutical effects.

Prior to program administration, the indication for the trainings should be made by a child and adolescent psychiatrist/psychotherapist who clinically diagnoses the adolescent DMRD based on the ICD-11 criteria of GD/HG (World Health Organisation, 2022) and carefully assesses potential mental comorbidities. The latter should be treated based on current standards. DMRD screening instruments (GADIS, SOMEDIS, STREDIS) are applied to parents and adolescents and evaluated before or at the beginning of the first program appointment (Paschke, Austermann et al., 2022; Paschke et al., 2020, 2021a, 2021b, 2023; Paschke, Napp, et al., 2022).

Both group trainings have been constructed comparably with 8 sessions each and a booster session 6 to 8 weeks after the last session. The duration of an individual session is estimated at 60 to 90 minutes and sessions are conducted weekly. Before entering the program, a joint appointment for each participating family is scheduled to give introductory information, define goals, develop a family-based reinforcement plan, and increase program commitment. Additionally, a midterm and a final family session is conducted to evaluate progress and potential changes over the time of the program on an individual family basis.

Res@t can be administered in (partially) inpatient or outpatient settings and follows a partially open concept so patients can enter the training at predefined times.

Res@t-A (Offline)

Setting

The adolescent program is recommended for a group of 4–10 participants between 10 and 19 years. The ability to work, communicate, and concentrate in a group for about 60 minutes must be fulfilled by all participants. Consequently, a non-treated ADHD, a severe autism spectrum disorder, intellectual disabilities, insufficient language skills, or a massive lack of motivation in combination with oppositional defiant disorder might be exclusion criteria for group participation. Further exclusion criteria cover acute psychosis and acute suicidality as well as substance intoxications.

According to the qualitative interview study of Wendt et al. (2021), a heterogeneous age group is of potential benefit for the younger ones to learn from older participants as role models and for the older ones to take over responsibility and experience self-efficacy in helping others while bearing the challenge to address the needs of different developmental stages. However, in clinical practice the organization of separate groups for younger (e. g., up to 14 years) and older participants (e. g., 15–19 years) might be advisable. Depending on the group size, an experienced child and adolescent psychotherapist should guide the training either alone or together with a health professional. A closed group structure might be ideal although the program is designed to meet potential clinical demands of flexibility. Within a half-open structure, it is recommended for patients to be enrolled within the first four sessions.

Content

The eight-week program focuses on improving self-awareness, knowledge and (intra-/inter-) personal skills (see Figure 1). The individual family appointments together with the first two sessions cover change motivation, goal setting, reinforcement strategies, and psychoeducation on PG including diagnostic criteria, etiology, and a personal contributing factors. Adolescents are assigned to one out of two teams in which subsequent tasks are administered and reinforcers can be earned to increase group coherence and commitment. Subsequent sessions address strategies of self-control for gaming time reduction, sleep hygiene and sleep-wake patterns, daily structures and activities outside the digital world, self-care, emotion regulation abilities, as well as social and communication skills. The last session is dedicated to the topic of relapse prevention and the development of an emergency kit for difficult situations. The booster session refreshes important contents and provides room for the participant’s experiences of the previous eight weeks. Additionally, at the beginning of each session a mindfulness exercise is performed to introduce techniques of relaxation and focus and provide a short warm-up. Participants are encouraged to fill in a daily calendar throughout the training on sleeping and gaming times, non-digital activities, self-control strategies, as well as mood and tension to promote self-observation and self-reflection. An exchange between participants and working in teams is also encouraged within every session.

Figure 1 Program structure of Res@t-A offline.

To increase motivation and specifically address the interests of the young target group, gamification elements are used throughout the training. This includes the creation of a personal avatar within the family appointment as a training companion, the assignment to one of two teams at the entry of the training, and a personalized training plan connected to individual and group rewards. The training plan works as a token system. Points can be earned for individual and for team achievements. Individual achievements include the fulfilment of weekly training tasks and filling out the tracking chart daily. Group achievements include the successful completion of group tasks within the sessions. Within the training participants start as a “Newbie” (rank 1). From there, they can reach the following four ranks: (2) “beginner”, (3) “skilled”, (4) “senior” and (5) “expert”. Reaching a new rank is connected to an individual reward which has been agreed on together with the parents during the first family appointment. Potential team rewards are determined by each team in the first session.

Evaluation

The Res@t-A program is currently being evaluated in a study with pre-post-follow-up design. The estimated sample size of the pilot study includes 30 participants from the (partial) inpatient setting at the clinical section of the German Center for Addiction Research in Childhood and Adolescence at the University Center Hamburg-Eppendorf (UKE). All patients here have confirmed PG together with mental comorbidities that are treated within a multimodal concept. Comorbidities mainly include ADHD, depression, and anxiety disorders. An outpatient sample is investigated at the Clinic for Child and Adolescent Psychiatry at the University Hospital Kiel. In addition, an English-language version adapted to the needs of Australian adolescents and an accompanied pilot study has been launched in collaboration with the Macquarie University (Prof. Warburton and colleagues) in Sydney in October 2022. Perspectively, a Mandarin-language version adapted for Chinese adolescents will be developed and tested in collaboration with the Fudan University in Shanghai (Prof. Behnisch and colleagues). Study outcomes are PG symptom reduction (primary outcome) as well as the improvement of self-efficacy expectancy, emotional and behavioral problems, emotion-regulation abilities, psychological stress perception, and sleep quality (secondary outcomes) operationalized by standardized questionnaires.

Res@t-P (Offline)

A detailed description of the setting, content, and pilot study evaluation can be found in a recent publication (Hülquist et al., 2022). A summary is given below.

Setting

Res@t-P is recommended to take place in a group setting of up to 10 parents, either individually or with the partner on a weekly basis. All participating parents must be able to work, communicate, and concentrate in a group for about 90 minutes. Hence, insufficient language skills, intellectual disabilities, or severe mental disorders might be exclusion criteria.

As mentioned above, the program should take place in parallel to the affected child’s treatment. However, if no treatment is yet available for the child or the child refuses professional help, Res@t-P might function as a bridging offer. A (child and adolescent) psychotherapist experienced with family and group sessions should conduct the training together with a health professional. As with the adolescent program, group coherence will benefit from a closed group structure. However, in the clinical context this might not be realizable in all cases. Within a half-open structure, new parents could be enrolled after every second session.

Content

The aim of Res@t-P is to support parents of affected adolescents by providing psychoeducation, promoting reflection and interparental exchange on experiences and personal issues including functions as role models and parenting behavior, fostering communication skills and stress management for improved health behavior during the eight-week program (see Figure 2). Consequently, parental self-efficacy and other parenting factors should improve as well as family communication and functioning. Moreover, parents’ psychological stress perception should decrease. These factors should support the child’s symptom reduction.

Figure 2 Program structure of Res@t-P offline.

The first two sessions concentrate on PG psychoeducation with diagnostic criteria and the introduction of models on general and child-specific etiology with the identification of risk factors. Sessions three to six cover the implementation and establishment of parenting rules under consideration of the child’s developmental stages, reinforcement learning mechanisms, and the introduction of family council meetings, the reflection on parenting styles, and the sensitization for validating communication strategies, as well as parental role model functions. The last two sessions address parental and family (mental) health, stress perception and management, the support of the child’s daily structures and alternative activities, the parent-child relationship and relapse prevention with building awareness for risk situations and creating emergency plans. A booster session after six weeks repeats important training contents and an exchange of the participant’s experiences. As in Res@t-A, each session starts with a mindfulness exercise for relaxation and a joyful warm-up as well as a personal reflection of the previous week. Weekly sessions should be complemented by training tasks connected to the session topics. Parents are encouraged to reflect their own media-use behavior by completing a daily calendar (“tracking chart”) throughout the training.

Evaluation

The feasibility of Res@t-P was evaluated in a pilot study using a pre-post-follow-up design without control group (Hülquist et al., 2022). 43 parents of affected adolescents with PG were included in the study. At three measurement points (before, at the end, six weeks after the training) standardized questionnaires on parental stress perception, family communication, family functioning, media rules, and adolescent PG symptoms were collected. Conditional growth models revealed an improvement in family functioning, communication, and the application of media rules. Moreover, a reduction of parental stress and PG symptoms was shown. These results are promising regarding the effectiveness of Res@t-P in the treatment of PG. However, interpretation is limited as the study was conducted as part of a treatment package with the children of the participating parents being in outpatient or (partial) inpatient treatment themselves parallel to the parental training, the sample size was rather small, and no control group could be followed. A subsequent study in randomized controlled trial (RCT) design with waiting control group and a bigger sample size is currently in planning.

Res@t-A and -P Digital (Res@pp)

Setting

Given rising DMRD prevalence on the one hand, and limited treatment offers on the other, it is aimed to make Res@t available to a greater number of patients, independent of their region of living. Therefore, the content of Res@t-A and -P has been translated into a digital application for individual use together with the technical partner and expert for e-mental health Embloom, Maastricht. Disorder-specific elements for the treatment of SMUD and SD will be added. The app is intended to complement ongoing treatment (blended therapy) or to be used standalone in cases of at-risk media usage without comorbidities or as a bridging offer before analogue treatment is available.

Res@pp comprises 10 sessions of approximately 20 minutes in length. New sessions will be made available weekly with exception of the booster session which will be activated 5 weeks after session 9. Reminders should encourage parents and adolescents to fill in the daily calendar on mood and activity times including media usage, and to complete individual modules. Parents and adolescents should receive independent but parallel trainings that convey the contents of the offline programs. Exclusion criteria for the program are insufficient language skills as well as acute psychosis and acute suicidality.

Content

The content is adopted from Res@t-A und Res@t P offline to fit into a digital version (see Figure 3). The first session includes a description of the training, its purposes, and contents, the formulation of training goals, and the creation of a reward plan in cooperation with the parents. The following sessions correspond to modules one to eight of the offline trainings. Each session starts with a graphical summary of the calendar including times of media consumption, non-digital activities, and sleep. After the introduction to each week’s session, a short mindfulness exercise is administered via a demonstrative video including detailed verbal instructions. This is followed by four quests that include quizzes (via multiple-choice questionnaires, sorting, drag and drop), informative videos, and fill-in sections to personalize content. Motivating feedback is given on each fulfilled quest and completed module. Content presentations include text, videos, audios, and graphics. During the course of the training, positive interactions between parents and their child are fostered though suggestions for perspective changes, family meetings, and joint activities. Res@pp content will be attractively presented in an appealing design to provide user-friendly interaction with the content.

Figure 3 Program structure of Res@t-A and –P digital (Res@pp)

Evaluation

The effectiveness of Res@pp is planned to be evaluated based on the CONSORT (Consolidated Standards of Reporting Trials) international guide to guarantee study quality (Schulz et al., 2010). Accordingly, a multi-center randomized pre-post-follow-up trial with waitlist control group is planned to reduce bias. The waitlist control group will receive treatment as usual and get access to the intervention after data collection. A change in adolescent DMRD symptoms and parental self-efficacy will be measured as primary outcomes for the adolescents/parents with standardized instruments. Secondary outcome measures will include psychological and familial health factors (i. e. stress, sleep, communication) using standardized psychometric tests and neurophysiological tests in a subgroup. Based on predefined inclusion and exclusion criteria, 13 340 children and adolescents in routine outpatient care shall be screened for DMRD and checked on for study suitability by child and adolescent psychiatrists and psychotherapists at 40 to 50 practices, five large care clinics and three university hospitals in Germany. A total of 1334 participants is aimed to be included in the study equally randomized to both arms. In addition, a subsample of adolescents with learning disabilities and school absenteeism will be recruited and investigated within an individual tailored blended-therapy approach. It is hypothesized that the treatment group will show a higher reduction in DMRD symptoms (Res@t-A) and more parental self-efficacy (Res@t-P) than the control group. Multilevel modeling will be used for data evaluation. Moreover, implementation-related factors will be examined quantitatively and qualitatively to identify specific conditions for success and their impact on effectiveness. These include knowledge on reach, willingness to use, acceptance by stakeholders (patients, parents, practitioners), and identification of needs and required resources (long-term) implementation. Ethical approval will be acquired by the local ethics committee.

Discussion

Res@t is a newly created CBT-based program package comprising offline group treatments for adolescents with PG (Res@t-A; Wendt et al., 2021) and parents of affected adolescents (Res@t-P; Hülquist et al., 2022) as well as a digital version for both target groups (Res@t-A and -P digital [Res@pp]). It is based on a multifactorial treatment approach in line with the current state of research on the complex etiology of PG and related DMRD (e. g. Paulus et al., 2018; Sugaya et al., 2019). By involving adolescents and parents in a symptom-specific treatment, a more effective intervention to reduce DMRD symptoms can be assumed. Given rising prevalence and a lack of effective and broadly available treatments, a manualized and evaluated program for DMRD in children and adolescents is urgently needed.

First evaluation results of Res@t-P offline are promising regarding an improvement of parental self-efficacy as well as family factors and a reduction of PG symptoms. Hence, generalizability of the results is highly limited at this stage due to the pilot study design without control group and a rather small sample size. Yet, given the lack of alternative therapy options, and limited resources, a waiting control group would have been ethically difficult at this time of the study. Moreover, sample size is comparable to other pilot intervention studies in the field (Besser et al., 2022; González-Bueso et al., 2018; Torres-Rodríguez et al., 2018).

Pilot data on the effectiveness on Res@t-A offline are currently collected in Germany and Australia. Adolescents reported positive experiences and good acceptance of the group so far. RCT studies on both offline programs are planned to follow the highest scientific standards. Despite urgent needs, RCT studies are largely missing in the field of DMRD and especially with adolescent-parent target groups (Zajac et al., 2020).

To allow a better reach, independent of the experience and availability of therapists, Res@t-A and -P have been translated into an app (Res@pp) that can be used either standalone or within a blended therapy approach. In addition to PG, problematic use of social media and video streaming platforms will be therapeutically addressed. A multi-center RCT study will be performed to evaluate program effectiveness.

The manuals of Res@t-A and -P are planned to be published in 2023 to make the new treatment programs accessible and easy to use for clinicians. They were developed to provide user-friendly guidance for clinical practice based on latest research results and profound clinical experience in the field of DMRD. According to Carroll and Nuro (2002) the development of psychotherapy manuals should follow three stages: (i) Treatment development and performance of pilot studies, (ii) methodology design with RCTs to evaluate treatment efficacy, and (iii) the application in different (clinical) contexts and its evaluation regarding effectiveness and costs. All stages have been or will be addressed within the Res@t research project.

In conclusion, Res@t is the first fully manualized treatment package for adolescents with DMRD and their parents applying different settings (group vs. app-based) with the potential to close a significant gap within the treatment of this rising phenomenon.

Implications for Clinical Practice

  • •
    Res@t is a CBT-based intervention package to treat adolescents with DMRD and their parents to account for a multifactorial etiology.
  • •
    Res@t is designed for group settings and transferred into a digital application for individual use.
  • •
    Res@t aims to reduce significant gaps in the treatment of DMRD in adolescents, which lacks manualized and evidence-based programs.
  • •
    Res@t-A (for adolescents) and Res@t-P (for parents) manuals will be made available in 2023.
  • •
    Multicenter RCT studies are highly warranted and currently planned to evaluate Res@t.

We thank the Res@t team, especially (in alphabetically order) Dr Nicolas Arnaud, Prof Thomas Behnisch, Katharina Bitter, Hannah Brauer, Ivo Buil, Katharina Busch, Dr Silke Diestelkamp, Nicole Fangerau, Sylvia Hansen, Martin Hoff, Joel Hülquist, Thomas Krömer, Linus Lorenz, Stanni Otten, Johanna Philippi, Prof Dr Alexander Prehn-Kristensen, PD Dr Olaf Reis, Paul Röhr, Ina Schloss, Anna-Lena Schulz, Maria Stark, Bart van Viggen, Frank Visser, Felix von Warburg, Prof Wayne Warbuton, Prof Antonia Zapf, and all committed clinical partners and participating families.

References