Therapist perspectives on training in a package of evidence-based practice strategies for children with autism spectrum disorders served in community mental health clinics

Mental health providers' perceptions of competency when working with autistic children with co-occurring mental health diagnoses

Psychotherapy research has long focused on provider competence and treatment efficacy. Mental health providers treat diverse client populations with varying, complex needs. Though estimates vary, the rate of children diagnosed with autism and a co-occurring psychiatric disorder is relatively high. While behavioral approaches to treatment have been established as the gold standard, talk-based therapies are increasingly common, and a broader range of providers are treating this population. There are gaps in the literature regarding empirically supported, targeted approaches, and provider sense of competency in addressing complex needs. The aim of this secondary qualitative analysis was to gain further insights into mental health providers' experiences of psychotherapy with autistic children with a cooccurring diagnosis. Eleven licensed clinicians participated in semistructured interviews. The following themes emerged: perception of competency, complex needs, and family involvement. Recommendations for a collaborative approach, increased opportunities for training, and standardized, targeted assessments and treatment protocols were made.

Stakeholder engagement to inform evidence-based treatment implementation for children’s mental health: a scoping review

Background

There is a pervasive mental health treatment gap for children across the globe. Engaging stakeholders in child mental health evidence-based treatment (EBT) implementation projects may increase the likelihood of successful EBT implementation, thereby better addressing the treatment gap. However, little is known about the extent of stakeholder engagement to inform the implementation of child mental health EBTs.

Methods

We conducted a scoping review to characterize stakeholder engagement in child mental health EBT implementation projects, including what stakeholders are engaged, how they are engaged, when they are engaged, where they are engaged (i.e., location of projects), why they are engaged, and the reported impacts of stakeholder engagement. We searched seven databases: MEDLINE, PsycInfo, Embase, ERIC, CINAHL Complete, Scopus, and Web of Science Core Collection. To be included, studies had to report on some form of stakeholder engagement that was undertaken to inform or explain the implementation of a child mental health EBT. We performed data extraction and synthesis to describe key study and stakeholder characteristics, stakeholder engagement methods and rationales, reported impacts of stakeholder engagement, and quality of reporting on stakeholder engagement.

Results

In total, 122 manuscripts met our inclusion criteria, from which we identified a total of 103 unique child mental health EBT implementation projects. Projects spanned 22 countries, which included low-, lower-middle, upper-middle, and high-income countries. The largest number of projects was in the USA and conducted in public mental health settings. Most projects engaged EBT providers during the active implementation phase and with limited depth, often gathering information from stakeholders without sharing decision-making power in implementation efforts. Across projects, impacts of stakeholder engagement spanned all of Proctor and colleague’s implementation outcomes.

Conclusions

Given that stakeholder engagement is often shallow and with limited shared decision-making, additional effort should be made to increase engagement to preempt challenges to EBT implementation and ensure implementation success. Such efforts may ensure the just distribution of power in EBT implementation efforts.

Trial registration

All procedures were pre-registered on the Open Science Framework prior to conducting the literature search (DOI 10.17605/OSF.IO/GR9AP).

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00327-w.

Delivering and implementing child and adolescent mental health training for mental health and allied professionals: a systematic review and qualitative meta-aggregation

BACKGROUND

The increasing prevalence of mental health difficulties among children and young people (CYP) suggests that early intervention is vital. A comprehensive system of care and support requires the involvement of mental health professionals, including psychologists and psychiatrists, and allied professionals, including teachers, police, and youth workers. A critical starting point is the provision of effective training, in order that these professionals can better support the mental health needs of the CYP that they encounter.

OBJECTIVES

Given the primacy of training in the CYP mental health support system, understanding the factors that maximise potential gains and facilitate uptake is pertinent. The current review therefore located and explored qualitative research evidence, to identify the barriers and facilitators underpinning successful delivery and implementation of training focussed on the mental health of CYP, for both mental health and allied professionals.

METHODS

A systematic review and qualitative meta-aggregation were conducted. Systematic searches were carried out using ASSIA, EMBASE, MEDLINE, NICE Evidence, PsycINFO, and Scopus databases, for papers published between 2000 and 2020. Twelve thousand four hundred forty-eight records were identified, of which 39 were eligible for review. The records were appraised for quality using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research, and synthesised using the qualitative meta-aggregation method.

RESULTS

One hundred eighty-two raw findings were extracted from the 39 papers, which were condensed into 47 sub-categories, 19 categories, and finally 5 synthesis statements. These synthesis statements reflected the barriers and facilitators influencing the training delivery process ("support"; "content, design, and planning"), and the implementation of training into the workplace ("context"; "perceived value"; "organisational factors").

CONCLUSIONS

The synthesis statements and underlying categories provide practical recommendations for those designing, delivering, or implementing CYP mental health training. Recommendations ranged from facilitating peer support during training, to the idea that training will be better implemented when perceived need is high. The review provides a robust evidence-based foundation to "common-sense" principles, drawing them into a coherent and organised framework using a synthesis method grounded in pragmatism.

PROTOCOL REGISTRATION NUMBER

PROSPERO reference ID: CRD42020162876.

Characterizing Shared and Unique Implementation Influences in Two Community Services Systems for Autism: Applying the EPIS Framework to Two Large-Scale Autism Intervention Community Effectiveness Trials

The purpose of this study was to examine common and unique factors influencing implementation process for two evidence-based interventions for children with autism spectrum disorder (ASD) in mental health and education service contexts. This study prospectively collected qualitative data from intervention developers and research staff on the implementation process within the context of two separate ASD intervention effectiveness trials. Results reveal common and unique factors influencing implementation in both study contexts. Implementation leadership and provider attitudes and motivation emerge as key influences on implementation across systems. These findings provide promising targets for modular implementation interventions that can be leveraged within growing, large-scale translation efforts in usual care.

Impact of Therapist Training on Parent Attendance in Mental Health Services for Children with ASD

OBJECTIVE

The current study explored the impact of training therapists in a mental health intervention for children with autism spectrum disorder (ASD) on parent attendance in their children's therapy sessions. We also examined family, therapist, and program factors as potential moderators.

METHOD

Data were drawn from a cluster-randomized community effectiveness trial of "An Individualized Mental Health Intervention for ASD (AIM HI)". Participants included 168 therapists yoked with 189 children recruited from publicly-funded mental health services. Data included family (caregiver strain, parent sense of competence, race/ethnicity), therapist (background, experience), and program (service setting) characteristics, and parent session attendance. Multilevel models were used to evaluate the effectiveness of AIM HI therapist training on caregiver attendance and identify moderators of training effects on parent attendance.

RESULTS

Parents attended a higher percentage of sessions in the AIM HI training condition compared to the Usual Care condition. Program service setting moderated the effect of AIM HI training, with higher parent attendance in non-school (mostly outpatient) settings compared to school settings and a significantly smaller difference between the settings in the AIM HI condition.

CONCLUSIONS

Effective strategies to promote parent engagement, especially in service settings such as schools, are warranted. Findings support the effectiveness of AIM HI training in promoting parent attendance across multiple publicly-funded mental health service settings. The larger effect in school-based programs supports the utility of training in evidence-based interventions such as AIM HI to increase the feasibility of parent attendance in such services.

A Mixed-Method Analysis on the Impacts of a System-Driven Implementation of Multiple Child Evidence-Based Practices on Community Mental Health Providers

Initiatives to scale up evidence-based practices (EBPs) in routine care are likely to have myriad impacts on community providers, but these impacts have not yet been examined in depth. This is especially true within the context of simultaneous implementation of multiple evidence-based practices. The aim of this study was to characterize the multifaceted impacts on community mental health therapists within a system-driven implementation of multiple EBPs for youth and families. Semistructured interview and survey data were gathered from 60 therapists at 11 agencies contracted with the Los Angeles County Department of Mental Health to deliver EBPs within the Prevention and Early Intervention initiative. Therapists' accounts of impacts varied, and were either predominately negative, predominantly positive, or mixed-valence. Mixed-methods analyses using Kruskal-Wallis tests showed therapist valence groups varied on mean levels of self-reported burnout on surveys. Themes from qualitative data revealed several favorable (e.g., increased EBP knowledge, structure) and unfavorable (e.g., distress, feeling constrained by EBPs) impacts of county-contracted EBP implementation. These findings inform the development and implementation of future system-driven EBP initiatives that consider therapist perspective to optimize positive impacts and minimize negative impacts on therapists.

Adaption and pilot implementation of an autism executive functioning intervention in children's mental health services: a mixed-methods study protocol

BACKGROUND

Youth with autism spectrum disorder (ASD) represent a growing population with significant service needs. Prominent among these needs are high rates of co-occurring psychiatric conditions that contribute to increased functional impairments and often necessitate mental health services. Executive functioning deficits are associated with ASD as well as common co-occurring conditions (e.g., attention-deficit/hyperactivity disorder) and an evidence-based intervention has been developed and tested to address executive functioning within the school context. There is an urgent need to implement indicated evidence-based interventions for youth with ASD receiving care in community mental health settings. Interventions that optimally "fit" the mental health services context as well as the complex and co-occurring mental health needs of these youth have the potential to improve key clinical outcomes for this high priority population.

METHODS

This mixed-methods developmental study will apply the Exploration, Preparation, Implementation, Sustainment implementation framework and a community-academic partnership approach to systematically adapt and test an evidence-based executive functioning intervention for youth with ASD for delivery in community mental health settings. Specific aims are to (1) conduct a need and context assessment to inform the systematic adaptation an executive functioning evidence-based intervention; (2) systematically adapt the clinical intervention and develop a corresponding implementation plan, together entitled "Executive Functioning for Enhancing Community-based Treatment for ASD," (EFFECT for ASD); and (3) conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.

DISCUSSION

Tailoring evidence-based interventions for delivery in community-based mental health services for youth with ASD has the potential to increase quality of care and improve child outcomes. Results from the current study will serve as the foundation for large-scale hybrid implementation and effectiveness trials and a generalizable approach for different service systems of care and clinical populations.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04295512.

Emergent life events in the delivery of a caregiver-mediated evidence-based intervention for children with autism spectrum disorder in publicly funded mental health services

LAY ABSTRACT

Mental health clinicians often report significant challenges when delivering evidence-based interventions (EBI) in community settings, particularly when unexpected client stressors (or emergent life events; ELEs) interfere with the therapy process. The current study sought to extend the study of ELEs to children with Autism Spectrum Disorder (ASD) by examining the occurrence and impact of ELEs in the context of a collaborative, caregiver-mediated intervention for reducing challenging behaviors in children with ASD. This intervention was An Individualized Mental Health Intervention for children with ASD (referred to as AIM HI). Participants included 38 clinicians and child clients who were enrolled in a community effectiveness trial of AIM HI. Video recordings of 100 therapy sessions were coded for caregiver-reported ELEs and also how well clinicians adhered to the AIM HI protocol. Results indicated that mild to severe ELEs were reported in 36% of therapy sessions, and were reported for 58% of children at some point during the intervention. Children who had a greater number of diagnoses (in addition to the autism diagnosis) tended to have more ELEs. In addition, clinicians with less years of experience tended to have sessions with more ELEs. There was no significant link between ELEs and how well clinicians adhered to the AIM HI protocol. Findings offer implications for the implementation of EBI, particularly the importance of incorporating clinician training in addressing complex presentations and crises in the context of EBIs.

Effectiveness of Training Therapists to Deliver An Individualized Mental Health Intervention for Children With ASD in Publicly Funded Mental Health Services: A Cluster Randomized Clinical Trial

IMPORTANCE

Publicly funded mental health services play an important role in addressing co-occurring mental health problems in children with autism spectrum disorder (ASD); however, therapists report lacking training to effectively serve this complex population.

OBJECTIVE

To test the effectiveness of training community therapists in An Individualized Mental Health Intervention for ASD (AIM HI) on challenging behaviors across 18 months among children with ASD and identify moderators and mediators of any intervention effects.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial conducted in 29 publicly funded outpatient and school-based mental health programs in southern California from 2012 to 2017. Programs were randomized to receive immediate AIM HI training or provide usual care followed by receipt of AIM HI training. Therapist participants were recruited from enrolled programs, and child participants were recruited from participant therapists' caseloads. Data were analyzed from 202 children with ASD who were aged 5 to 13 years.

INTERVENTIONS

The AIM HI protocol is a package of parent-mediated and child-focused strategies aimed to reduce challenging behaviors in children with ASD who are 5 to 13 years old. It was designed for delivery in publicly funded mental health services based on a systematic assessment of therapist training needs and child clinical needs. The therapist training and consultation process takes approximately 6 months and includes an introductory workshop, 11 structured consultation meetings as the therapist delivers AIM HI with a current client, and case-specific performance feedback from trainers.

MAIN OUTCOMES AND MEASURES

Child participants were assessed for challenging behaviors using the Eyberg Child Behavior Inventory (ECBI) and Social Skills Improvement System (SSIS) Competing Problem Behaviors scales based on parent report at baseline and at 6-month intervals for 18 months. Outcomes were analyzed using intent-to-treat models.

RESULTS

In total, 202 children with ASD (mean [SD] age, 9.1 [2.4] years; 170 [84.2%] male; 121 [59.9%] Latinx) were eligible, enrolled, and included in the analyses. Statistically significant group by time interactions for the ECBI Intensity (B = -0.38; P = .02) and ECBI Problem (B = -1.00; P = .005) scales were observed, with significantly larger decreases in ECBI Intensity scores in the AIM HI group (B = -1.36; P < .001) relative to the usual care group (B = -0.98; P < .001) and a significantly larger decrease in ECBI Problem scores in the AIM HI group (B = -1.22; P < .001) relative to the usual care group (B = -0.20; P = .29). Therapist fidelity moderated these intervention effects.

CONCLUSIONS AND RELEVANCE

The present findings support the effectiveness of training therapists to deliver the AIM HI model to children with ASD receiving publicly funded mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02416323.

Comparing Agency Leader and Therapist Perspectives on Evidence-Based Practices: Associations with Individual and Organizational Factors in a Mental Health System-Driven Implementation Effort

Agency leaders and therapists are essential stakeholders in implementation of evidence-based practices (EBPs) within publicly-funded mental health services. Little is known about how these stakeholders differ in their perceptions of specific EBPs and which individual and organizational factors differentially influence these perceptions. Within the context of a system-driven implementation of multiple EBPs, survey data from 160 leaders and 720 therapists were examined to assess differences in perceptions of six EBPs. Findings indicated that leaders and therapists have unique perspectives and preferences regarding EBPs that are shaped by distinct sociodemographic and professional characteristics and aspects of organizational functioning.

Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster randomized trials

BACKGROUND

The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes. However, research on generalizable methods to scale up these practices in the multiple service systems caring for these children has been limited and is critical to meet this growing public health need. This project includes two, coordinated studies testing the effectiveness of the Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy (TEAMS) model. TEAMS focuses on improving implementation leadership, organizational climate, and provider attitudes and motivation in order to improve two key implementation outcomes-provider training completion and intervention fidelity and subsequent child outcomes. The TEAMS Leadership Institute applies implementation leadership strategies and TEAMS Individualized Provider Strategies for training applies motivational interviewing strategies to facilitate provider and organizational behavior change.

METHODS

A cluster randomized implementation/effectiveness Hybrid, type 3, trial with a dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants. Study #1 will test the TEAMS model with AIM HI (An Individualized Mental Health Intervention for ASD) in publicly funded mental health services. Study #2 will test TEAMS with CPRT (Classroom Pivotal Response Teaching) in education settings. Thirty-seven mental health programs and 37 school districts will be randomized, stratified by county and study, to one of four groups (Standard Provider Training Only, Standard Provider Training + Leader Training, Enhanced Provider Training, Enhanced Provider Training + Leader Training) to test the effectiveness of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes. Implementation outcomes including provider training completion, fidelity (coded by observers blind to group assignment) and child behavior change will be examined for 295 mental health providers, 295 teachers, and 590 children.

DISCUSSION

This implementation intervention has the potential to increase quality of care for ASD in publicly funded settings by improving effectiveness of intervention implementation. The process and modules will be generalizable to multiple service systems, providers, and interventions, providing broad impact in community services.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov ( NCT03380078 ). Registered 20 December 2017, retrospectively registered.

Psychosocial interventions for internalizing disorders in youth and adults with ASD

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

Adapting Psychological Therapies for Autism - Therapist Experience, Skills and Confidence

BACKGROUND

Psychological interventions informed by cognitive behavioural theory have proven efficacy in treating mild-moderate anxiety and depression. They have been successfully adapted for autistic children and adults who experience disproportionately high rates of co-occurring emotional problems. There has been little research into the perspectives and experience of psychological therapists adapting cognitive behavioural therapy (CBT) as part of routine clinical practice. We surveyed therapist skills, experience and confidence in working psychologically with autistic people, in order to highlight gaps and needs, as well as strengths in terms of therapist skills when working with this group.

METHOD

Fifty therapists attending a training event completed a survey about their experience of adapting CBT for autistic clients, alongside a measure of therapist confidence.

RESULTS

Almost all therapists reported making adaptations to CBT practice when working with autistic clients. Key challenges identified were rigidity in thinking and pacing sessions appropriately. Therapists were relatively confident about core engagement and assessment skills but reported less confidence in using their knowledge to help this group. Therapist confidence was not associated with years of practice or number of adaptations made, but was positively associated with level of therapy training received.

CONCLUSIONS

This study highlights a need for training and ongoing supervision to increase therapist confidence in and ability to make appropriate adaptations to CBT treatment protocols for autistic people.

Stakeholder perspectives on a toolkit to enhance caregiver participation in community-based child mental health services

Client engagement in services is a critical element of effective community-based child and family mental health service delivery. Caregiver engagement is particularly important, as caregivers often serve as gatekeepers to child mental health care and typically must consent for services, facilitate service attendance, and are often the target of intervention themselves. Unfortunately, caregiver engagement has been identified as a significant challenge in community-based child mental health services. To address this gap, the Parent And Caregiver Active Participation Toolkit (PACT), which includes therapist training and participation tools for caregivers and therapists, was developed. Stakeholders' perspectives regarding the delivery of interventions designed to improve the quality and effectiveness of community-based care are essential to understanding the implementation of such interventions in routine service settings. As such, this mixed methods study examined the perspectives of 12 therapists, 8 caregivers, and 6 program managers who participated in a community-based randomized pilot study of PACT. Therapists, caregivers, and program managers agreed that PACT was acceptable, appropriate, and feasible to use in community settings and that both changes in therapist practices and caregiver participation resulted from implementing PACT. Some variable perceptions in the utility of the therapist training components were identified, as well as barriers and facilitators of PACT implementation. Results expand the parent pilot study's findings as well as complement and expand the literature on training community providers in evidence-based practices. (PsycINFO Database Record

Toward the implementation of evidence-based interventions for youth with autism spectrum disorders in schools and community agencies

Evidence-based interventions (EBIs) for youth with autism spectrum disorders (ASD) are rarely found in community settings where most youth with ASD receive services. Implementation research designed to help bridge this gap is needed. However, efforts to implement EBIs in community settings face a number of barriers. The main purpose of this article is to illustrate how making EBIs more flexible and integrative may help improve their utility and may increase their uptake by stakeholders in community mental health and school settings. We conclude with an example of a modular, stepped-care program that might help bridge the science-practice gap in the ASD field by combining elements of a number of existing EBIs into a single, flexible intervention.

Contributing death factors in very low-birth-weight infants by path method analysis

Background:

Neonatal deaths account for 40% of deaths under the age of 5 years worldwide. Therefore, efforts to achieve the UN Millennium Development Goal 4 of reducing childhood mortality by two-thirds by 2015 are focused on reducing neonatal deaths in high-mortality countries. The aim of present study was to determine death factors among very low-birth-weight infants by path method analysis.

Materials and Methods:

In this study, medical records of 2,135 infants admitted between years 2008 and 2010 in neonatal intense care unit of Alzahra Educational-Medical centre (Tabriz, Iran) were analysed by path method using statistical software SPSS 18.

Results:

Variables such as duration of hospitalisation, birth weight, gestational age have negative effect on infant mortality, and gestational blood pressure has positive direct effect on infant mortality that at whole represented 66.5% of infant mortality variance (F = 1018, P < 0.001). Gestational age termination in the positive form through birth weight, and also gestational blood pressure in negative form through hospitalisation period had indirect effect on infant mortality.

Conclusion:

The results of the study indicated that the duration of low-birth-weight infant's hospitalisation is also associated with infant's mortality (coefficient -0.7; P < 0.001). This study revealed that among the maternal factors only gestational blood pressure was in relationship with infants’ mortality.