Use of technology in evidence-based programs for child maltreatment and its impact on parent and child outcomes

Introduction Technology has been used in evidence-based child maltreatment (CM) programs for over a decade. Although advancements have been made, the extent of the application of technology in these programs, and its influence on parental and child outcomes, remains unclear within the context of changes that emerged because of the COVID-19 pandemic. This scoping review provides a contextualized overview and summary of the use of technology in evidence-based parenting and child programs serving families impacted by child maltreatment and the effects of technology-enhanced programs on target outcomes. Materials and methods Using Arksey and O'Malley's methodological framework, we searched seven databases to identify peer-reviewed and grey literature published in English from 2000 to 2023 on evidence-based programs, according to the California Evidence-Based Clearinghouse (CEBC), that included technological supports for two populations: at-risk parents for child maltreatment prevention, and children and youth 0–18 years exposed to child maltreatment. All study designs were included. Results Eight evidence-based parenting programs and one evidence-based child trauma program were identified as using technology across a total of 25 peer-reviewed articles and 2 peer-reviewed abstracts meeting inclusion criteria (n = 19 on parent-level programs; n = 8 on child-level programs). Four studies were published in the context of COVID-19. Two main uses of technology emerged: (1) remote programmatic delivery (i.e., delivering all or part of the program virtually using technology) and (2) programmatic enhancement (i.e., augmenting program content with technology). Improvements across parenting and child mental health and behavioral outcomes were generally observed. Discussion Technology use in evidence-based child maltreatment programs is not new; however, the small sample since the start of the COVID-19 pandemic in this review that met inclusion criteria highlight the dearth of research published on the topic. Findings also suggest the need for the inclusion of implementation outcomes related to adoption and engagement, which could inform equitable dissemination and implementation of these programs. Additional considerations for research and practice are discussed.


Introduction
Child maltreatment remains a national public health priority in the US with nearly 600,000 cases substantiated in 2021, and approximately 1,820 deaths related to singular or co-occurring incidents of physical abuse, sexual abuse emotional abuse, and neglect (1). More recent evidence suggests global physical abuse and psychological abuse rates of 18% and 39%, respectively, during the first years of the coronavirus pandemic, COVID-19 (2). Youth exposed to child maltreatment are vulnerable to a host of short-and long-term biological and psychosocial adverse outcomes (3)(4)(5). At-risk parents, the primary perpetrators of CM (1), may also be victims of trauma, and experience deficits in executive functioning and emotion regulation that amplify negative parenting behaviors (6-10). High-risk families experience several chronic stressors such as part-time employment, economic hardship, trauma history and mental health symptomology (8,9). COVID-19 placed exceptional demands on high-risk minority families, who were at not only increased risk for contracting the virus, but at disproportionate risk of unemployment and psychosocial distress attributed to increases in financial and social support instabilities (11). Such disruptions to family routine and external resources have played a role in reports of increased burnout among caregivers (12), and the possibility of abuse against children (13-16).
An abundance of evidence exists for the effectiveness of evidence-based programs in addressing adverse outcomes among caregivers as well as child and youth victims. Of note, behaviorally-based child maltreatment prevention programs are founded on the assumption that child maltreatment risk resulting from parenting skill deficits can be improved by providing parents training in a repertoire of skills, using a specific instructional format that includes: (1) education or instruction on target skills, (2) behavioral modeling of target skills, (3) parent practice of skills through role plays and live practice with the child, and (4) feedback to parents (17). Importantly, these skills have been found to be critical to parent behavior change in a meta-analysis of parent training programs by Kaminski and colleagues (18). Research suggests that parenting programs for caregivers with increased risk of child maltreatment perpetration lead to reductions in child maltreatment potential, such as parental stress via self-report and biomarkers (19)(20)(21), as well as improvements in parent-child interactions, home safety, child healthcare skills, and other caregiver (e.g., maternal social support, maternal depression, non-violent discipline) and child outcomes (e.g., adaptive functioning, behavioral risk) (22)(23)(24)(25)(26)(27)(28).
Similar improvements are seen among youth engaged in evidence-based psychotherapeutic programs for child and youth trauma associated with child maltreatment exposure, which are often based in behavioral and cognitive restructuring frameworks as well as trauma-focused strategies to address the psychological impact of trauma among youth (29,30). These programs may use multiple techniques over the course of treatment to change thoughts and behaviors of trauma-affected youth and their caregivers, such as psychoeducation and coping exercises (e.g., relaxation via breathing, meditation). For example, in the gold-standard child-sexual abuse intervention, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), providers implement components defined by the acronym "PRACTICE": (1) psychoeducation and parenting, (2) relaxation, (3) affective expression and modulation, (4) cognitive coping, trauma narrative processing, (5) in vivo exposure, (6) conjoint parentchild sessions, and (7) enhancing safety (31). Such evidencebased programs are associated with notable changes across child behavior and mental health symptomology, including decreases in post-traumatic stress disorder symptomology, abuse-related fears, sexualized behavior, depression, anxiety, shame, and behavior problems among traumatized youth (29, [32][33][34]. Despite the proven effectiveness across these programs for both parents and children, reaching and retaining families in real-life practice is a substantial challenge in general. However, the availability and delivery of such scientifically supported programs were critical during the height of the pandemic, as the "pandemic paradox" (35) created by social distancing regulations to reduce spread of infection had unintended consequences for families; indeed, caregivers were placed at greater risk of stress in the household and child maltreatment perpetration. In response to national public health guidelines, agencies offering evidencebased practices rapidly adapted in-person delivery to a virtual delivery approach to prevent disruptions in service provision for vulnerable populations (36). In addition, telehealth guidelines were released for aforementioned well-supported behavioral treatment TF-CBT, which provided considerations for both providers and families on equipment, privacy, internet stability, and safety (37). As such, the pandemic heightened awareness of the utility and importance of digital platforms for services.
The field of child maltreatment prevention and treatment has considered technological platforms for program delivery and augmentation for over a decade prior to COVID-19 (the CDC first funded projects to explore such efforts in 2006), though dissemination and implementation of these approaches were very limited in standard practice (for examples, see the Introduction to the Special Issue on Using Technology to Address Child Maltreatment: Prevention, Intervention, and Research (38, 39). However, almost three years following the pandemic onset, it is unclear how the use of technology in practice has evolved to support child maltreatment evidence-based prevention and intervention program access and effectiveness. Because the pandemic necessitated the use of virtual program delivery, it is imperative that we learn from the data and information gathered prior to and during this period that can inform how we should move forward with leveraging telehealth and other technology to improve program access, efficiency, and effectiveness. For instance, preliminary data collected during 2020 suggest that virtual sessions are feasible for delivering child maltreatment programs typically delivered in the home (40,41). Emerging evidence suggests that virtual and/or technology-augmented delivery of evidence-based child maltreatment programs originally designed to be delivered in person decrease program access barriers, improve program efficiency, increase family attendance and service completion, and lead to similar program outcomes as in-person delivery (41-44).
Yet, barriers exist for virtual delivery, including technology access, concerns about the quality of care, and how differing delivery approaches can impact program fidelity. Many questions remain, and thus, a comprehensive synopsis of technology use in practice across parent and child-level programs is needed to summarize evidence on not only these technological developments, but the effectiveness of these adaptations on measured outcomes among parent and child populations. This scoping review provides a contextualized overview and summary of the use technology in evidence-based parenting and child programs serving families impacted by child maltreatment, and the impact of technological methods, as available, on measured outcomes over the past two decades.

Study design
A scoping review was chosen, in contrast to a systematic review, as the method of choice to synthesize and describe the breadth of available studies using various research methodologies without analytic comparisons, allowing for a comprehensive summary of the published literature that can guide future research directions as well as practice and policymaking (45). In accordance with Arksey and O'Malley's (46) framework, this scoping review included five stages of methodology: (1) development of specific review questions, including the definition of participants and establishment of inclusion criteria, (2) a comprehensive search of the published and grey literature; (3) selection of relevant studies; (4) charting of identified data; (5) summary and discussion of the results in the context of the field and future directions.

Identification of objectives and research questions
The objective of this research was to understand how technology can be better leveraged and understood to improve evidence-based child maltreatment programs. Our goals were to describe the evidence-based programs, the nature of technology incorporated, the nature of change across measured maltreatment-related outcomes.
As such, we posed the following questions: (1) How has technology been used in evidence-based parenting and child/youth programs for child maltreatment from 2000 to 2023? (2) What are the effects of technology-enhanced programs measured population outcomes?

Definitions
For the purposes of this review, evidence-based programs were defined as prevention programs at the parent level, or interventions at the child level rated as well-supported, supported, or promising through the Scientific Rating Scale established by the California Evidence-Based Clearinghouse (CEBC).
This review presents findings on two distinct populations affected by child maltreatment: parents and children. Parent populations were defined as the primary caregivers who are atrisk of perpetration or who have perpetrated child maltreatment. Child populations were defined as child or youth victims of child maltreatment, under 18 years of age.

Inclusion criteria
Eligibility criteria for studies were established using the PICO framework (i.e., participants, interventions, comparators, outcomes) as seen in Table 1. In general, this review included studies published in English from 2000 to 2023 on evidencebased programs for child maltreatment prevention among at-risk parents or evidence-based treatment for sequelae among children 0-18 years of age exposed to abuse. Of note, the year 2000 was chosen as a key period when close to 50% of Americans were using the internet (45), or likely used a cell phone (47), or owned a computer (48).
In addition, studies must have tested technological supports in the intervention for inclusion. Studies with provider informants reporting on population outcomes were also included in this work. All study designs were eligible for inclusion, such as pilot studies, qualitative accounts, cross-sectional studies, and effectiveness/efficacy trials. Exclusion criteria included protocol papers, discussion papers and field notes that did not include empirical data.

Identification of relevant published literature
As mentioned, the review was designed to be inclusive of published peer-reviewed articles and select grey literature (e.g., conference abstracts, dissertations, reports) in the past two decades, between 2000 and 2023. The search extended across several subject areas including public health, psychology, medicine, education, and social work. Publications were identified using the following databases: Embase, Education  (46), we worked with university librarians with expertise in scoping reviews to identify key words and execute a comprehensive search across databases. Searches were performed using identified key words and related MeSH terms across five domains of interest (see Tables 2, 3 for list of keywords and search strings, respectively).

Selection of relevant studies
A preliminary search of PubMed was conducted using key word string combinations and established MeSH terms. This step was taken to confirm the relevance of key terms in netting eligible articles. A comprehensive search across listed databases was conducted following the completion of the pilot literature search. Additional steps were taken to screen reference lists of retrieved and relevant publications. Special issues from leading family violence journals were also reviewed for completeness of search.
The research team uploaded retrieved citations into Endnote (49), a reference and citation manager, to facilitate organization of studies and duplicates removal. Following duplicates removal, the primary researcher created a comprehensive library that was used to screen relevant caregiver-and child-level publications. Screening procedures were conducted as follows: Three members of the research team (AT, MR, JG) independently screened titles and abstracts for eligibility criteria, keywords, and MeSH terms. All noted programs in publications were cross-compared to the CEBC for evidence-based intervention research ratings. Full-text articles were retrieved for all potentially relevant studies. We also retrieved full texts of articles with abstracts with ambiguous relevance during screening. At this stage, the three researchers screened retrieved articles for inclusion in results. Discrepancies were resolved by the lead researcher (AT) as they arose.

Data charting
Identical charting procedures were made for caregiver and child population findings as follows: Upon establishment of final eligible articles, two researchers used Microsoft Excel to first extrapolate study characteristics, including but not limited to: author information, publication year, publication type, population and sample size, location, intervention and evidencebased rating, technological adaptation identified, study design, and outcomes and/or key findings. Team members met as needed to discuss iterative changes as they emerged. Figure 1 illustrates the flowchart of selection of final articles in the study. Using the previously mentioned key words, an initial search yielded 3,336 articles. Upon removal of 635 duplicate articles and an initial screening process removing 2,701 titles, we assessed 100 full text articles for eligibility criteria. Our final set of studies included 25 peer reviewed articles, and 2 peer-reviewed abstracts examining evidence-based parenting (n = 18 peerreviewed articles; n = 1 peer-reviewed abstract), or child-level programs (n = 7 peer reviewed articles; n = 1 peer-reviewed abstract) using technology. Two major uses of technology across all programs emerged and were coded during data extraction-(1) remote programmatic delivery, or (2) programmatic enhancement. We define remote programmatic delivery as the complete, or hybrid use of virtual technology such as videos, recordings, or video conferencing platforms via data or internet channels to synchronously or asynchronously deliver all program components. Programmatic enhancements were defined as the use of technology to augment therapeutic content and goals inperson or between sessions. Below we summarize findings across the parent and child-level programs and report on the use or technology, and evaluation of program outcomes as available. An overview of all evidence-based parenting and youth/child programs identified can be found in Table 4.  "Guardians" or "Parents" or "caregivers" or "mothers" or "fathers" or "youth" or "children" or "child" or "adolescent" OR "parents" [MeSH]) AND ("Child maltreatment" or "child abuse" or "child trauma" or "neglect" or "child physical abuse" or "child sexual abuse" or "child neglect" or "child maltreatment" [MeSH] or "child sexual abuse" [MeSH] or "battered child syndrome"

Evidence-based parenting programs overview
Nineteen studies (See Table 5) described or evaluated use of technology using data across the following eight evidence-based parenting programs: ACT Raising Safe Kids (n = 1), Attachment and Biobehavioral Catch-up (n = 1), Healthy Families America (n = 1), The Incredible Years (n = 1), Parents as Teachers (n = 1), Play and Learning Strategies (PALS) (n = 2), SafeCare (n = 7), and the Positive Parenting Program (Triple P) (n = 5). Data were available from five countries, including, the U.S., Australia, Brazil, Canada, and New Zealand, through single site and one multisite study. One study specifically focused on adolescent pregnant girls (54). Three studies provide reports in the context of the COVID-19 pandemic (41, 51, 56). Of these, two studies were conducted among providers engaged in parenting program delivery, who shared qualitative accounts of participant progress through the program (41, 42). A detailed description of findings across all studies is provided below, presented by type of technology used in programs.

Remote programmatic delivery
More than half of the included studies on evidence-based parenting programs (n = 10) reported on telehealth or online delivery of programmatic content. The majority of articles described full telehealth delivery of content. Only two described the use of hybrid, or asynchronous programmatic delivery to participants. Four studies noted provision of loaned equipment to facilitate remote delivery procedures to families (53,54,60,67).
(42) describe an early account of a web based SafeCare via tablet, in which providers noted positive reception among families, citing feasibility benefits to using audio and visual aids for programmatic delivery. Five years later, Self-Brown and Scoping review PRISMA flowchart.

Enhancements
Eight studies on evidence-based parenting programs described alternative uses of technology, specifically to augment program

Program targets Program as prescribed Application
Parenting Programs ACT-Raising Safe Kids (50) The ACT Raising Safe kids is a parenting program that teaches positive parenting and parent anger management skills. The program also creates a community support system with other parents in the program.
Eight or nine weekly 2-hour sessions that include didactic instruction, group activities, discussion, and role play.
Lotto et al. (51) e-PALS Baby-Net Program (52) e-PALS is an online version of Play and Learning Strategies (PALS) that uses online content to strengthen the parentchild relationship by teaching parents how to interpret and respond to babies' signals and utilize rich language.
Eleven 90 min home visits which include video of parent and child interacting and video playback to review behaviors.
Baggett et al. (53) Feil et al. (54) Incredible Years (55) The Incredible Years program strengthens parenting and fosters parental involvement in child education to improve children's skills and conduct.
Two to three-hour parent group sessions are provided once per week for 12-20 weeks.
Camero et al. (56) Healthy Families America (57) Healthy Families America is a home-visiting program aimed at promoting positive parent-child interactions and secure attachments and building protective factors.
Home visits occur for 50-60 min weekly. After standardizing family progress, visits are conducted on a bi-weekly, monthly, then quarterly basis until graduation.
Parents as Teachers (PAT) The PAT program is a home visiting program used to increase parent knowledge about child development and parenting practices, identification of child developmental delays and health issues, prevent child maltreatment, and boost children's school readiness and success.
Two-year (recommended) program including home visits, group meetings, and annual child health screenings. The number of one-hour home visits ranges from 12 to 24 home visits depending on needs.
Traube et al. (60) SafeCare (61) The parent-child and/or parent-infant interactions module teaches how to interact positively with their child, perform engaging activities, and address their children's challenging behaviors. The ABC program has 3 components: teaching caregivers to interpret children's behavioral signals and provide nurturing care, helping caregivers provide a responsive and positive environment to enhance children's' behavioral and regulatory capabilities, and helping caregivers reduce behaviors overwhelming or frightening to a child.
Ten, weekly, one-hour sessions that incorporate video-feedback and homework activities.
Schein et al. (67) Triple P (68) The Triple P Positive Parenting Program is a five-tiered system that promotes parental confidence and competence, positive parenting strategies, child self-regulation, and parent communication.
The Triple P system consists of five tiers of intervention that vary in intensity. Triple P Online (72) Triple P Online is an extension of Triple P that provides online support to parents to address challenging child behaviors, teach positive parenting skills, and promote emotional self-regulation.
Eight online modules are delivery virtually as well as video demonstrations and computer-assisted goal setting.
Sanders et al. (73) Child/Youth Trauma Program  (26,62,64,65), as well as web-supported audio and video content to supplement evidence-based program content (78). Of note, in many of these applications, participants were provided with needed technology devices during the intervention (26, 64, 65). One additional technological enhancement was the optimization of the Healthy Families home visiting program though an internet-based, tablet delivered, eight session eparenting program designed to address child maltreatment risk (58). The e-parenting program curriculum was grounded in three effective evidence-based models (i.e., SafeCare, motivational interviewing and cognitive retraining). Ondersma et al. (58) note the use of video-based skill modeling and feedback as part of the e-program. The enhancement demonstrated feasibility in its implementation, as well as positive reception among parents, but parent ratings of relevance were low. Improvements in maternal depression symptomology and perpetration risk were observed following intervention completion but were not maintained at 6 or 12 month follow up in comparison to services as usual and control groups (58).
Two studies also describe the use of online discussion forums as strategies for evidence-based programs to build group-based support systems among participating families (52,79). One population-based study also described strategies for broad-based dissemination of programmatic material to increase program awareness in target communities (70).

Evidence-based child focused trauma programs overview
Eight child-level intervention studies were identified for inclusion in this study (See Table 6), all examining effects of technology across one intervention, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Data were collected from the U.S. (n = 6), Canada (n = 1), and Puerto Rico (n = 1). Importantly, only one study examined data collected during the pandemic COVID-19 context.

Remote programmatic delivery
Most studies (n = 6) described implementation of synchronous, virtual delivery via HIPAA compliant telehealth video conferencing software such as "Vidyo" to delivery program content (39,(74)(75)(76)(77)80). In several instances, families were provided with iPads during therapy to facilitate telehealth delivery [for examples, see: (74, 75,80)]. As part of the TF-CBT telehealth process, several studies also cited the use of technological adaptations during delivery to meet the remote needs of children and youth. Sessions may have included use of digitized materials such as books, games, and video clips to convey content to clients. Additional software, including Microsoft Word and Adobe, were mentioned as applications allowing participants to make edits to documents that were shared with providers (39,74,75,77,80).
Of note, one study also described the use of both remote delivery and supplemental enhancement strategies to increase engagement between sessions (80). In this work, providers contacted participants via calls and text messages for session and homework reminders.
Although safety assurance plans for youth were likely implemented during the pandemic, only two telehealth-based studies explicitly alluded to inclusion during implementation. For example, Orengo-Aguayo et al. (77) describe the use of consultation calls to review safety concerns among therapists as treatment sessions were conducted, whereas, Stewart and colleagues (39) detail strategies in school and home settings including regular communications and presence of school staff and presence of caregivers or trusted contacts during sessions.

Technological enhancements
Two studies were identified that presented unique augmentations to TF-CBT. Both studies were also published using data collected prior to the pandemic. While varying in approaches and purpose, both studies noted significant improvements across internalizing symptomology and posttraumatic stress disorder among participating youth. First, Davidson et al. (82) piloted "tablet TF-CBT", which included 11 tablet-based activities targeting constructs within the TF-CBT model and general mental health programs, designed to increase provider-client engagement. These activities were built in consultation with providers and considered embedded under the category of "available tools for providers" in the fidelity monitoring process. Second, a Canadian study by Caouette et al. (81) piloted the embedment of an Attachment Video-feedback Intervention (AVI) with TF-CBT, to measure changes in parentchild relationships. AVI was integrated as a video-feedback component for caregivers during psychoeducation to address parent-child interactions. The authors describe that this discussion added half hour to session length, and that protocol for each intervention was followed as prescribed (81).

Discussion
This scoping review summarizes the use technology in evidence-based parenting child maltreatment prevention programs and child trauma therapy programs over the past two decades, inclusive of the recent COVID-19 pandemic years. We identified a total of eight parenting-focused programs, and one child-focused program across twenty-seven published works examining the use of technology in practice prior to, and since the onset of the pandemic. Our findings highlight the consistent presence of technology in remotely delivering services, and/or to enhance program content among target populations. Irrespective of the classification, technological advancements in practice were generally associated with positive parent and child mental health and behavioral outcomes in all geographic contexts and sample populations.
Although these results support the integration of technology in practice, the observed positive impact can be limited with low buy- in or feasibility in practice. However, review findings among parents and children across the 11 studies measuring participant satisfaction on the use of both telehealth and explored digital enhancements were generally encouraging. Indeed, these studies noted favorable reception or satisfaction rates among users, which may be a proxy indicator of perceived quality or engagement within these technologically advanced evidencebased programs. Conflicting findings, as with Ondersma et al. (58), may suggest otherwise, where positive reception to technology-based changes to programs did not equate to perceptions of relevance or positive program effects as observed.
It is important to note; however, that the software included in this study, though very advanced at the time of the trial (2006-2009), holds very little relevance to the advancements that emerged in the last decade, and this could be a driver of the relatively poorer reception. Additionally, parent and child comfort and experience with using technology over the last decade has dramatically increased and has become standard in our social communications and general experiences with education, which could also substantially increase perceived relevance and satisfaction.
Other studies in this review, such as Baggett et al. (53) have shown that other feasibility indicators, such as increased session dosage, may be associated with stronger program outcomes. Collectively, these data emphasize that the investigation of associations between implementation measures and participant engagement, as well as with target outcomes among programs adopting technology is in its early stages at best, and even less explored in relation to specific uses such as telehealth and/or technological enhancements. Studies should include additional measured constructs across quality, dosage, and adherence for greater understanding of optimal approaches during program implementation.
While not a key focal population of this review, providers as the implementing agents of these evidence-based programs are a non-traditional but important group that can enhance our understanding of the feasibility and effectiveness of technological integration. Noting provider voice, in addition to clients, as part of development and testing of technology-based delivery approaches and augmentations is of utmost importance. Without provider or therapist buy-in to the use of technology as part of evidence-based practice delivery, there will be challenges with implementation. For example, Stewart et al. (74) described strong satisfaction amongst therapists with their telehealth delivery process, noting both comfort in using telehealth equipment as well as interactions with youth over digital technology. In contrast, in Self-Brown's (41) study on SafeCare implementation during the pandemic, providers described the logistic struggles faced by their families during telehealth delivery, as well as barriers in formatting program content and with conducting observational assessments using virtual delivery. General studies on therapist perspectives have also documented similar (83), as well as novel reflections on remote delivery considerations since the pandemic onset, such as quality and effectiveness of treatment (83-86), safety management in the home environment (85)(86)(87) and even provider virtual fatigue (83,84). Such responses are key assessments that can shape directions for best practices for using technology in the context of human services.

COVID-19 context
An interesting observation from this review was the limited number of articles focused on technology use and effectiveness in the context of parenting and child programs published since the onset of the pandemic. This may be due in part to the arduous and lengthy process of peer-reviewed publication, which can take up to 2 years from time of submission to publication. However, the aforementioned recommendations across agencies to adopt telehealth suggests that many evidencebased programs were, indeed, utilizing such technology to meet the needs of families during the pandemic. The limited available evidence is promising, but more studies are sorely needed in this area.
Moreover, it is critical to explore how well these programs approached, or are approaching, implementation-related outcomes, especially fidelity monitoring, or protocol adherence measurement, in real-world practice as pragmatic adaptations during delivery were likely to occur. Fidelity is critical as programs implemented as designed are noted to achieve positive outcomes (88)(89)(90). Several of the parenting and child program studies published prior to the pandemic describe formal fidelity monitoring for telehealth as well as technological enhancements [data not shown; for examples, see: (42, 60,82)]. Evidence-based parenting programs such as Parents as Teachers established support systems for technical assistance during telehealth delivery (60). In contrast, in their web-based application of SafeCare, Self-Brown and colleagues (42) note use of a provider fidelity checklist that accommodated adaptations made during the implementation of their web-based program. However, in the COVID-19 context, few have documented evidence of strong provider fidelity during implementation of a telehealth program (67,77,91,92), and only one, included in the current study, with likely related effectiveness in improving parental outcomes (67).

Practice-based considerations
There is no dispute that real-time, digital delivery of programs can reduce geographic barriers for families who are likely burdened with numerous stressors. Our findings suggest that telehealth and programmatic enhancements are effective in increasing participation and improving outcomes among parent, youth, and child populations. Yet despite general satisfaction, positive indications of feasibility, and the unique position of telehealth options to alleviate geographic restrictions, developers and practitioners must continue to address formidable challenges around general program enrollment in addition to long waitlists as seen in child trauma programs, which may not be fixed with technology advents. Irrespective of how engaging a program may Tiwari et al. 10.3389/fdgth.2023.1224582 Frontiers in Digital Health be, no observable effects will be noted without service-level supports and strong recruitment and retention strategies.
Research must also focus on how well remotely delivered programs can effectively assess child safety, a hallmark of the child protection system in child maltreatment response. In other words, even in the presence of safety assurance plans, are providers able to accurately assess child safety and maltreatment risk, observing the home environment and key parent-child interactions? Nonetheless, the use of various technological devices reflects the market of options available to assist with programmatic dissemination. As cell phones and tablets become more ubiquitous in use (47), these devices may become appropriate choices to engage with participants in and out of sessions and expand the reach of programmatic content. Uptake and incorporation of such technology in standard practice does come with caveats; as the question of digital equity regarding access to cellular data and connectivity remains (41), limiting the ecological validity of positive findings across highlighted efficacy studies in this review. We must continue to consider the present digital divide exacerbated by the pandemic (93), which faces many vulnerable families who are often the targets of these programs. One solution seen among studies was the provision of internet ready devices, which may assist with improving equity in access to care and higher engagement rates among parent and child populations. Yet, the removal of resource constraints among families will not address the logistic barriers seen at the provider level. For example, in the context of SafeCare during the pandemic, providers described logistic barriers with virtual translation of program content intended for in-person assessment, in which they experienced difficulties modeling skills and home assessments (41).
A key question regarding the inclusion of more technologybased applications in evidence-based programs then becomes, what information is potentially lost or enhanced in the process? In one school of thought, Mowbray et al. (94) classify essential programmatic content as structural (i.e., key components), or as process related (i.e., interactions, and rapport). If left unaddressed, logistic limitations could prohibit delivery of core program components and in turn, expected outcomes. It is encouraging to note that some programs are specifically addressing logistical limitations through tailoring of process-related content while maintaining structural content (i.e., fidelity to the model) when delivering interventions via telehealth (74). Promisingly, parent, youth and child accounts among included studies suggest that telehealth experiences and digital enhancements did not interfere with rapport building with providers (60). As we shift towards delivery with digital influences, programs should maintain some flexibility in delivery approaches, but rigor to the core components of the curriculum that is key to the mechanistic drivers of outcomes must be incorporated to ensure expected outcomes. Moving forward, technology could also be used in precision home visiting to strengthen the implementation of core components and efficiency of programs to serve the needs of diverse populations.
While our review captured the application of technology in evidence-based programs for child maltreatment, it is important to note additional existing literature in this area was not captured by through our search string or database selection. For example, artificial intelligence is a growing area of interest in data modeling of violence prevention to identify algorithms for perpetration and prevention (95). The current review did not include search parameters for this novel interface. However, with additional exploration, this technology will be important to assess within evidence-based programs in the future. Further, many established programs, with high relevance for preventing maltreatment and published technology research, were not captured because the technologybased modifications were applied to other target populations not captured in our search. For example, the Parent-Child Interaction Therapy (PCIT), an evidence-based program targeting child behavioral or externalizing mental health symptomology has been modified for remote delivery in its Internet delivered PCIT format, which uses comparable videoconferencing technology among families (96, 97). Though PCIT has also been shown to positive impact families at risk for child maltreatment (98) these studies focused on families with children experiencing significant behavioral issues (96). Several other non-evidence, based but emerging programs also describe digital advancements to promote outcomes, or are original digital interventions providing treatment (see Tables 7, 8).
As one example, studies on smartphone app interventions, such as the JoyPop application which is based on trauma-informed principles, have demonstrated improvements in resilience and mental health symptomology and among young adult populations with a history of adverse childhood experiences. Preliminary evidence also supports the incorporation of JoyPop among both evidence-based parent (99,100) and child programs (101). Such advancements represent new directions in technology providing rapid access to behavioral care. In consideration of the increased use of technology-based applications in evidence-based practice, we must also assess whether the cost of these advents counterbalances the magnitude of benefits, and sustainability of programs, or contributes to the limitations observed in practice. Only through reliable evaluation of these programmatic advancements can we weigh the costeffectiveness in comparison to program efficacy. However, researchers and practitioners encounter limitations through federal funding requirements and current grant infrastructure, which prohibit rapid dissemination of quality science in emergent situations such as the pandemic. Concurrently, published findings then become irrelevant as reported upon technology become obsolete in the face of newer technological innovations entering the field.

Conclusions
This scoping review is the first to provide a comprehensive examination of uses and effects programs through technology enhancements, as applicable, across evidence-based CM programs for both parent and child populations. The incorporation of technology presents exciting possibilities for program success for many models and the pandemic represents an era of novel directions for the field. However, the notably few available studies are an indication of the need for extensive exploration of the role of technology in practice. Only with such research can we definitively comment on its true utility. Further, the benefit of these programs is based on their effectiveness in achieving positive outcomes for parents, youth, and children. A prominent challenge of the field will be to identify effective means of implementing programs with technology in a sustainable manner. We have growing opportunities to explore innovative technologies in practice to meet the needs of families and must continue to explore methods to promote behavioral change through empirically validated research testing the rigor of technology-based strategies in practice.

Author contributions
AT, SS-B, and VE contributed to the conception of the study. AT, VE, MR, JG, RM, SD, KO, and EP contributed to the search process; AT, MR, and JG contributed to the screening and final inclusion process; AT wrote the first draft of the manuscript; SS-B, contributed to sections of the manuscript; AT, MR, and JG Feel the ViBe (FtV) Internet-based support intervention that includes informational pages, a forum, a chat, and a "connect to expert" feature that connect the user to a community manager.
Internet-based imagery rescripting intervention Internet-based writing assignments based on CBT and imagery rescripting components which were reviewed by psychiatrist who provided written feedback.