Commentary: computer-based interventions in pediatric psychology.

The study by Davis, Quittner, Stack, & Yang (this issue) details an exciting and innovative approach to providing psychoeducation to pediatric populations. These investigators employed a CD-ROM to deliver in-office education and illness-related coping skills to children and adolescents with cystic fibrosis. Findings demonstrated significant increases in both knowledge and coping competency after only 30 minutes exposure to the computer-based materials. These findings are noteworthy because they suggest that a brief, selfdirected educational intervention can result in substantial improvements in outcomes that are the frequent target of psychoeducational interventions. Moreover, the intervention described can be delivered cost-effectively and with little professional involvement. This commentary seeks to examine Davis et al. (this issue) in the context of the broader field of computer-delivered interventions, variously referred to as e-health or telehealth, and to consider the opportunities and challenges that this emerging area poses for the field of pediatric psychology. A review article (Lewis, 1999) of computer-based approaches to patient education found that 16 of 21 research-based studies had medium to high effect sizes, suggesting that computer-based education is an effective strategy for improving knowledge and skills in individuals from medical populations. However, only 7 of the 66 identified articles (10.6%) pertained to pediatric populations. Although the earliest study of pediatric telehealth or computer-based interventions dates back to Rubin et al., 1986, subsequent studies in this area have been rare and have focused primarily on education and improved knowledge (Gleuckauf et al., 2002; Homer et al., 2000; Ritterband et al., 2003). Reasons for pediatric psychologists’ later adoption of new technologies is unclear. However, a recent survey of pediatricians’ attitudes toward electronic communications indicated that 79% did not want to use e-mail to communicate with patients’ families because of concerns regarding confidentiality and increased workload (Kleiner, Akers, Burke, & Werner, 2002). The following brief and noninclusive review of subsequent pediatric interventions provides a sense of the scope and nature of work in this area. Some investigators have followed Rubin et al.’s (1986) lead by translating standard asthma education materials into interactive office-based videogames (Bartholomew et al., 2000). In Homer et al. (2000), for example, an intervention had children’s responses determining whether the game character ‘‘Spacer’’ was able to progress to higher levels—through effective asthma management—or lost power/speed due to ineffective management of his asthma symptoms. Homer and colleagues found significantly greater improvements in knowledge in the computer-based education group versus the standard-care face-to-face education group, whereas Bartholomew et al. (2000) reported both increases in knowledge and reductions in asthma morbidity. Evidence from the cognition and instruction literature suggests that educational games are most apt to be effective when they are intrinsically motivating and engage the player’s mental representation of the knowledge domain (Wolfe, 2001). Other investigators have adopted an interactive multimedia education approach similar to the one reported by Davis et al. (Krishna et al., 2003). For example, Ritterband and colleagues (2003) reported findings from a Web-based family intervention for pediatric encopresis which demonstrated significant reductions in soiling accompanied by increased unprompted trips to the toilet and defecation in the toilet relative to a standard-care comparison group. Similar to the Davis et al. (in press) intervention, the encopresis website was self-guided and involved minimal additional input from health care professionals. However, it was home based and required an investment of approximately 6 hours of