Publications by authors named "Lauren Brookman-Frazee"

87 Publications

Train-to-Sustain: Predictors of Sustainment in a Large-Scale Implementation of Parent-Child Interaction Therapy.

Evid Based Pract Child Adolesc Ment Health 2021 8;6(2):262-276. Epub 2021 Jan 8.

University of California, Los Angeles, Department of Psychology.

Sustainment of evidence-based practices is necessary to ensure their public health impact. The current study examined predictors of sustainment of Parent-Child Interaction Therapy (PCIT) within a large-scale system-driven implementation effort in Los Angeles County. Data were drawn from PCIT training data and county administrative claims between January 2013 and March 2018. Participants included 241 therapists from 61 programs. Two sustainment outcomes were examined at the therapist- and program-levels: 1) PCIT claim volume and 2) PCIT claim discontinuation (discontinuation of claims during study period; survival time of claiming in months). Predictors included therapist- and program-level caseload, training, and workforce characteristics. On average, therapists and programs continued claiming to PCIT for 17.7 and 32.3 months, respectively. Across the sustainment outcomes, there were both shared and unshared significant predictors. For therapists, case-mix fit (higher proportions of young child clients with externalizing disorders) and participation in additional PCIT training activities significantly predicted claims volume. Furthermore, additional training activity participation was associated with lower likelihood of therapist PCIT claim discontinuation in the follow-up period. Programs with therapists eligible to be internal trainers were significantly less likely to discontinue PCIT claiming. Findings suggest that PCIT sustainment may be facilitated by implementation strategies including targeted outreach to ensure eligible families in therapist caseloads, facilitating therapist engagement in advanced trainings, and building internal infrastructure through train-the-trainer programs.
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http://dx.doi.org/10.1080/23794925.2020.1855613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259890PMC
January 2021

Correction to: A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes.

Adm Policy Ment Health 2021 Jul 1. Epub 2021 Jul 1.

Child and Adolescent Services Research Center, San Diego, CA, USA.

Due to the errors occurred in the originally published version, this article is being reprinted in its entirety as Correction. All errors have been corrected. It is the correct version.
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http://dx.doi.org/10.1007/s10488-021-01144-4DOI Listing
July 2021

Implementation of school-based services for students with autism: Barriers and facilitators across urban and rural districts and phases of implementation.

Autism 2021 Jun 16:13623613211016729. Epub 2021 Jun 16.

Child and Adolescent Services Research Center, USA.

Lay Abstract: The law requires that schools use evidence-based practices to educate students with autism spectrum disorder. However, these practices are often not used, or are not used correctly in school programs. Understanding barriers and facilitators of use of evidence-based practices in schools will help improve the implementation process. This study uses focus groups to characterize how school-based providers representing urban or rural school districts perceive barriers and facilitators for implementing new practices for students with autism spectrum disorder. Guiding questions include the following: (1) Are contextual factors perceived as barriers or facilitators and how do these vary by district location? and (2) What are the key factors impacting implementation across the Exploration, Preparation, Implementation, and Sustainment phases? Focus group participants ( = 33) were service providers to children with autism spectrum disorder from urban- and rural-located school districts. Several personnel-related themes (attitudes and buy-in, knowledge and skills, staffing, and burnout) were shared by participants representing both urban and rural districts. However, some personnel-related themes and organizational factors were unique to rural or urban districts. For example, themes related to system and organizational factors (leadership approval, support and expectations, district structure, competing priorities, time for effective professional development, litigation and due process, and materials and resources) differed between the district locations. This project serves as an initial step in identifying implementation strategies that may improve the use of evidence-based practices in schools.
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http://dx.doi.org/10.1177/13623613211016729DOI Listing
June 2021

A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes.

Adm Policy Ment Health 2021 Apr 21. Epub 2021 Apr 21.

Child and Adolescent Services Research Center, San Diego, CA, USA.

Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed.
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http://dx.doi.org/10.1007/s10488-021-01133-7DOI Listing
April 2021

Implementation facilitation strategies to promote routine progress monitoring among community therapists.

Psychol Serv 2021 Apr 1. Epub 2021 Apr 1.

Department of Psychology, University of California.

Despite substantial support for the importance of routine progress monitoring (RPM) as part of evidence-based practice, few providers utilize measurement-based care. This study sought to identify the relative importance of facilitation strategies viewed as most helpful for increasing intention to use RPM among 388 ethnically diverse community therapists serving children and families. Four types of facilitation strategies were examined: language/interpretability, automation, staffing/access, and requirements. Mixed analyses of variance found that therapists' reported intentions to use RPM were more influenced by strategies of automating assessment administration, provision of clerical assistance, and agency requirements than by making linguistically appropriate measures available. However, the importance of strategies differed depending on therapist race/ethnicity and current RPM use. Language/interpretability of RPM assessments was less emphasized for non-Hispanic White therapists and therapists who have not yet or only minimally adopted RPM compared with ethnic minority therapists and therapists who regularly use RPM, respectively. Furthermore, therapists who were not current RPM users emphasized automation more than staffing/access. Results may inform prioritization of implementation facilitation strategies for agencies to encourage RPM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/ser0000456DOI Listing
April 2021

Characterizing therapist delivery of evidence-based intervention strategies in publicly funded mental health services for children with autism spectrum disorder: Differentiating practice patterns in usual care and AIM HI delivery.

Autism 2021 Aug 28;25(6):1709-1720. Epub 2021 Mar 28.

Child and Adolescent Services Research Center, University of California, San Diego, USA.

Lay Abstract: This study was conducted to identify patterns of therapist delivery of evidence-based intervention strategies with children with autism spectrum disorder receiving publicly funded mental health services and compare strategy use for therapists delivering usual care to those trained to deliver AIM HI ("An Individualized Mental Health Intervention for ASD"), an intervention designed to reduce challenging behaviors in children with autism spectrum disorder. For therapists trained in AIM HI, intervention strategies grouped onto two factors, and , while strategies used by usual care therapists grouped onto a broader single factor, . Among usual care therapists, were related to an increase in child behavior problems, whereas for AIM HI therapists, were related with reductions in child behavior problems over 18 months. Findings support the use of active teaching strategies in reducing challenging behaviors in children with autism spectrum disorder and provide support for the effectiveness of training therapists in evidence-based interventions to promote the delivery of targeted, specific intervention strategies to children with autism spectrum disorder in mental health services.
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http://dx.doi.org/10.1177/13623613211001614DOI Listing
August 2021

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

J Clin Child Adolesc Psychol 2020 Aug 20:1-12. Epub 2020 Aug 20.

Child and Adolescent Services Research Center.

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.
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http://dx.doi.org/10.1080/15374416.2020.1796682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987108PMC
August 2020

Training Community Therapists to Deliver an Individualized Mental Health Intervention for Autism Spectrum Disorder: Changes in Caregiver Outcomes and Mediating Role on Child Outcomes.

J Am Acad Child Adolesc Psychiatry 2021 03 2;60(3):355-366. Epub 2020 Aug 2.

Child and Adolescent Services Research Center, San Diego, California; University of California, San Diego; San Diego State University, California.

Objective: This study examines the impact of training therapists to deliver "An Individualized Mental Health Intervention for Autism Spectrum Disorder (ASD)" (AIM HI) for children with autism spectrum disorder on caregiver outcomes and the mediating role of changes in caregiver outcomes on child outcomes.

Method: Data were drawn from a cluster randomized trial conducted in 29 publicly funded mental health programs randomized to receive AIM HI training or usual care. Therapists were recruited from enrolled programs and child/caregiver participants enrolled from therapists' caseloads. Participants included 202 caregivers of children 5 to 13 years of age with autism spectrum disorder. Caregiver strain and sense of competence were assessed at baseline and 6 month postbaseline. Child behaviors were assessed at baseline and 6, 12, and 18 months postbaseline. Therapist delivery of evidence-based intervention strategies were assessed between baseline and 6 months.

Results: A significant training effect was observed for caregiver sense of competence, with AIM HI caregivers reporting significantly greater improvement relative to usual care. There was no significant training effect for caregiver strain. Observer-rated therapist delivery of evidence-based interventions strategies over 6 months mediated training effects for sense of competence at 6 months. Changes in sense of competence from baseline to 6 months was associated with reduced child challenging behaviors at 6 months and mediated child outcomes at 12 and 18 months.

Conclusion: Combined with research demonstrating effectiveness of therapist AIM HI training on child outcomes, this study provides further evidence of the positive impact of training community therapists in the AIM HI intervention.

Clinical Trial Registration Information: Effectiveness and Implementation of a Mental Health Intervention for ASD (AIM HI); https://clinicaltrials.gov/; NCT02416323.
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http://dx.doi.org/10.1016/j.jaac.2020.07.896DOI Listing
March 2021

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

Pilot Feasibility Stud 2020 27;6:55. Epub 2020 Apr 27.

Child and Adolescent Services Research Center, San Diego, CA USA.

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.
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http://dx.doi.org/10.1186/s40814-020-00593-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371471PMC
April 2020

Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services.

Autism 2020 11 18;24(8):2094-2103. Epub 2020 Jul 18.

University of California, San Diego, USA.

Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.
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http://dx.doi.org/10.1177/1362361320934230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541440PMC
November 2020

Therapist-Observer Concordance in Ratings of EBP Strategy Delivery: Challenges and Targeted Directions in Pursuing Pragmatic Measurement in Children's Mental Health Services.

Adm Policy Ment Health 2021 01;48(1):155-170

Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA.

Pragmatic measures of therapist delivery of evidence-based practice (EBP) are critical to assessing the impact of large-scale, multiple EBP implementation efforts. As an initial step in the development of pragmatic measurement, the current study examined the concordance between therapist and observer ratings of items assessing delivery of EBP strategies considered essential for common child EBP targets. Possible EBP-, session-, and therapist-levels factors associated with concordance were also explored. Therapists and independent observers rated the extensiveness of therapist (n = 103) EBP strategy delivery in 680 community psychotherapy sessions in which six EBPs were used. Concordance between therapist- and observer-report of the extensiveness of therapist EBP strategy use was at least fair (ICC ≥ .40) for approximately half of the items. Greater therapist-observer concordance was observed in sessions where a structured EBP was delivered and in sessions where therapists reported being able to carry out planned activities. Findings highlighted conditions that may improve or hinder therapists' ability to report on their own EBP strategy delivery in a way that is consistent with independent observers. These results can help inform the development of pragmatic therapist-report measures of EBP strategy delivery and implementation efforts more broadly.
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http://dx.doi.org/10.1007/s10488-020-01054-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722101PMC
January 2021

Community providers' experiences with evidence-based practices: The role of therapist race/ethnicity.

Cultur Divers Ethnic Minor Psychol 2021 Jul 11;27(3):471-482. Epub 2020 May 11.

Department of Psychology, University of California, Los Angeles.

Objectives: Examining therapists' experiences implementing evidence-based practices (EBPs) is fundamental to understanding how these interventions are perceived, adapted, and delivered in community settings. However, little is known about racial/ethnic variation in the experiences of therapists serving racial/ethnic minority youth and their families. Through an innovative QUAN → qual → QUAN mixed-methods approach, we examined differences in therapists' perceptions, adaptations performed, and client-engagement challenges in the largest county-operated department of mental health in the United States.

Method: Surveys were completed by 743 therapists (Latinx [44%], White [34%], other ethnic minority [22%]), most of whom were female (88%), master's level (85%), and unlicensed (58%). A subset of therapists (n = 60) completed semistructured interviews.

Results: Latinx therapists reported more positive experiences implementing EBPs, making more adaptations to EBPs, and encountering fewer client-engagement challenges than therapists from other racial/ethnic groups. Qualitative analyses expanded on these results, revealing that Latinx therapists commonly described adapting EBPs in terms of language and culture to improve fit and promote client engagement. Informed by these qualitative themes, a refined statistical model revealed that the ability to deliver EBPs in languages other than English might have accounted for differences in therapist-reported EBP adaptations and client-engagement challenges.

Conclusions: The findings suggest that racial/ethnic minority therapists have positive experiences in implementing EBPs in community settings. In the case of Latinx therapists, bilingual/bicultural competence may facilitate adapting EBPs in ways that reduce perceptions of engagement challenges with racially/ethnically diverse clients. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cdp0000357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655698PMC
July 2021

Leveraging implementation science to reduce inequities in Children's mental health care: highlights from a multidisciplinary international colloquium.

BMC Proc 2020 6;14(Suppl 2). Epub 2020 Apr 6.

Child and Adolescent Services Research Center, San Diego, CA 92123 USA.

Background And Purpose: Access to evidence-based mental health care for children is an international priority. However, there are significant challenges to advancing this public health priority in an efficient and equitable manner. The purpose of this international colloquium was to convene a multidisciplinary group of health researchers to build an agenda for addressing disparities in mental health care access and treatment for children and families through collaboration among scholars from the United States and Europe engaged in innovative implementation science and mental health services research.

Key Highlights: Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, presentations related to inner, outer, and bridging context factors that impact the accessibility and quality of mental health evidence-based practices (EBPs) for children and families. Three common topics emerged from the presentations and discussions from colloquium participants, which included: 1) the impact of inner and outer context factors that limit accessibility to EBPs across countries, 2) strategies to adapt EBPs to improve their fit in different settings, 3) the potential for implementation science to address emerging clinical and public health concerns.

Implications: The common topics discussed underscored that disparities in access to evidence-based mental health care are prevalent across countries. Opportunities for cross-country and cross-discipline learnings and collaborations can help drive solutions to address these inequities, which relate to the availability of a trained and culturally appropriate workforce, insurance reimbursement policies, and designing interventions and implementation strategies to support sustained use of evidence-based practices.
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http://dx.doi.org/10.1186/s12919-020-00184-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132860PMC
April 2020

Adapting parent engagement strategies for an evidence-based parent-mediated intervention for young children at risk for autism spectrum disorder.

J Community Psychol 2020 05 1;48(4):1215-1237. Epub 2020 Apr 1.

Child & Adolescent Services Research Center, San Diego, California.

Aims: Aims included (a) characterizing provider feedback on parent engagement strategies integrated into a parent-mediated intervention for toddlers at risk for autism spectrum disorder (ASD) and (b) identifying provider characteristics that predict attitudes about parent engagement strategies.

Methods: A mixed method approach was utilized, including gathering quantitative data via survey (breadth) and collecting qualitative data via interview (depth). Acceptability, utility, appropriateness, sustainment, generalizability, and perceived effectiveness were examined. Fourteen agency leaders and 24 therapists provided input.

Results: Providers perceived the integration of parent engagement strategies as having a positive impact on implementation. Providers considered the strategies to be acceptable, appropriate, and effective, though barriers of time and complexity were noted. Provider characteristics did not consistently predict attitudes about the engagement strategies.

Conclusions: Incorporating parent engagement strategies into parent-mediated interventions for ASD is well-received by providers and may improve quality of service delivery for families served in early intervention for ASD.
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http://dx.doi.org/10.1002/jcop.22347DOI Listing
May 2020

Pediatric Primary Care Perspectives on Integrated Mental Health Care for Autism.

Acad Pediatr 2020 Nov - Dec;20(8):1140-1147. Epub 2020 Mar 20.

Department of Psychiatry, University of California (NA Stadnick, GA Aarons, DA Lee, and L Brookman-Frazee), San Diego, La Jolla, Calif; University of California San Diego Dissemination and Implementation Science Center (NA Stadnick, GA Aarons, and L Brookman-Frazee), La Jolla, Calif; Child and Adolescent Services Research Center (NA Stadnick, K Martinez, GA Aarons, DA Lee, and L Brookman-Frazee), San Diego, Calif; Rady Children's Hospital-San Diego, Autism Discovery Institute (L Brookman-Frazee), San Diego, Calif.

Objective: Timely identification of mental health needs and linkage to services is critical to provide comprehensive care for children with autism spectrum disorder (ASD). Pediatric primary care is well-positioned to facilitate this process through integrated care approaches. As a first step toward mental health integration, this study applied the Exploration, Preparation, Implementation, and Sustainment framework to characterize determinants of implementing integrated care practices for ASD.

Methods: Sixty pediatric primary care providers and leaders from 3 organizations completed focus groups and surveys about identification of mental health needs in children with ASD and access to mental health services. Findings were integrated to examine convergence (ie, do the 2 methods confirm or find similar results) and expansion (ie, do the 2 methods provide insights beyond either method alone).

Results: Results converged regarding 3 primary influences to integrated care practices for ASD: 1) limited specialized mental health referral options for ASD, 2) unique structural characteristics of the mental health system act as barriers to accessing care, and 3) caregivers differ in the degree to which they understand co-occurring mental health conditions and pursue recommended services. Qualitative results provided expansion by highlighting unique implementation considerations (eg, alignment with health care delivery priorities and values) based on primary care characteristics.

Conclusions: Findings confirm need for a tailored approach for linking children with ASD to appropriate mental health treatment. Results yield insight into the needs for organizational capacity to support integrated care and provide direction toward adapting an integrated mental health care model for children with ASD.
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http://dx.doi.org/10.1016/j.acap.2020.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502427PMC
July 2021

How community therapists describe adapting evidence-based practices in sessions for youth: Augmenting to improve fit and reach.

J Community Psychol 2020 05 25;48(4):1238-1257. Epub 2020 Feb 25.

Department of Psychology, University of California Los Angeles, Los Angeles, California.

The study sought to (a) characterize the types and frequency of session-level adaptations made to multiple evidence-based practices (EBPs) and (b) identify therapist-, client-, and session-level predictors of adaptations. Within the community implementation of multiple EBPs, 103 community mental health therapists reported on 731 therapy sessions for 280 clients. Therapists indicated whether they adapted EBPs in specific sessions and described adaptations in open-ended responses. Responses were coded using the Augmenting and Reducing adaptations framework. Therapists reported making adaptations in 59% of sessions. Augmenting adaptations were reported more frequently than Reducing adaptations. Multilevel logistic regression analyses revealed that greater therapist openness to EBPs, younger child age, and presenting problems was associated with Augmenting adaptations. Child presenting problem of externalizing problems predicted fewer Reducing adaptations compared with internalizing problems. This study extends the growing research examining adaptations within the context of the system-driven implementation of multiple EBPs by applying the Augmenting and Reducing adaptation framework to the session-level.
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http://dx.doi.org/10.1002/jcop.22333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261649PMC
May 2020

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.

Autism 2020 07 31;24(5):1286-1299. Epub 2020 Jan 31.

Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.

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 n ndividualized ental ealth ntervention 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.
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http://dx.doi.org/10.1177/1362361319881084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115197PMC
July 2020

Using stakeholder perspectives to guide systematic adaptation of an autism mental health intervention for Latinx families: A qualitative study.

J Community Psychol 2020 05 9;48(4):1194-1214. Epub 2019 Dec 9.

Department of Psychiatry, University of California San Diego, San Diego, California.

Embedded within a Hybrid Type 1 randomized effectiveness-implementation trial in publicly funded mental health services, the current study identified stakeholder recommendations to inform cultural adaptations to An Individualized Mental Health Intervention for Autism Spectrum Disorder (AIM HI) for Latinx and Spanish-speaking families. Recommendations were collected through focus groups with therapists (n = 17) and semi-structured interviews with Latinx parents (n = 29). Relevant themes were identified through a rapid assessment analysis process and thematic coding of interviews. Adaptations were classified according to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to facilitate fit, acceptability, and sustained implementation of AIM HI and classify the content, nature, and goals of the adaptations. Recommended adaptations were classified through FRAME as tailoring training and intervention materials, changing packaging or materials, extending intervention pacing, and integrating supplemental training strategies. Goals for adaptations included improving fit for stakeholders, increasing parent engagement, and enhancing intervention effectiveness. The current study illustrates the process of embedding an iterative process of intervention adaptation within a hybrid effectiveness-implementation trial. The next steps in this study are to integrate findings with implementation process data from the parent trial to develop a cultural enhancement to AIM HI and test the enhancement in a Hybrid Type 3 implementation-effectiveness trial.
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http://dx.doi.org/10.1002/jcop.22296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261618PMC
May 2020

Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children.

J Clin Child Adolesc Psychol 2020 Nov-Dec;49(6):868-882. Epub 2019 Dec 4.

Department of Psychiatry, University of California, San Diego and Child and Adolescent Services Research Center.

Objective: This study investigated a quality indicator for children's mental health, caregiver attendance in youth psychotherapy sessions, within a system-driven implementation of multiple evidence-based practices (EBPs) in children's community mental health services.

Method: Administrative claims from nine fiscal years were analyzed to characterize and predict caregiver attendance. Data included characteristics of therapists ( = 8,626), youth clients ( = 134,368), sessions (e.g., individual, family), and the EBP delivered. Clients were primarily Latinx (63%), male (54%) and mean age was 11; they presented with a range of mental health problems. Three-level mixed models were conducted to examine the association between therapist, youth, service, EBP characteristics and caregiver attendance.

Results: Caregivers attended, on average, 46.0% of sessions per client for the full sample and 59.6% of sessions for clients who were clinically indicated, based on age and presenting problem, to receive caregiver-focused treatment. Following initial EBP implementation, the proportion of caregiver attendance in sessions increased over time. Caregivers attended a higher proportion of youth psychotherapy sessions when clients were younger, had an externalizing disorder, were non-Hispanic White, and were male. Further, higher proportions of caregiver attendance occurred when services were delivered in a clinic setting (compared with school and other settings), by bilingual therapists, and the EBP prescribed caregiver attendance in all sessions.

Conclusions: Overall, the patterns of caregiver attendance appear consistent with evidence-informed practice parameters of client presenting problem and age. Yet, several improvement targets emerged such as client racial/ethnic background and service setting. Potential reasons for these disparities are discussed.
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http://dx.doi.org/10.1080/15374416.2019.1683851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269837PMC
February 2021

When Do Therapists Stop Using Evidence-Based Practices? Findings from a Mixed Method Study on System-Driven Implementation of Multiple EBPs for Children.

Adm Policy Ment Health 2020 03;47(2):323-337

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.

Therapist discontinuation of delivering an evidence-based practice (EBP) is a critical outcome in the community implementation of EBPs. This mixed methods study examined factors associated with therapist discontinuation within a large reimbursement-driven implementation of multiple EBPs in public children's mental health services. The study integrated quantitative survey data from 748 therapists across 65 agencies, and qualitative interviews from a subset of 79 therapists across 14 agencies. Therapists adopted, on average, 2.41 EBPs (SD = 1.05, range = 1-5), and nearly half (n = 355, 47.5%) reported discontinuing at least one EBP. Multi-level models were used to predict the binary outcome of discontinuation, and qualitative analyses were used to expand upon quantitative findings. Quantitative models revealed that therapist factors, including fewer direct service hours per week, a greater number of EBPs adopted, higher emotional exhaustion, and more negative attitudes toward EBPs in general were associated with discontinuation. In addition, EBP-specific factors including more negative perceptions of the particular EBP and lower self-efficacy for delivering the specific EBP predicted discontinuation. Themes from interview responses highlighted the importance of fit of the EBP with the agency's client base, as well as therapist perceptions of adequate EBP training supports, and the alignment of an EBP with therapists' professional goals. Together, the findings suggest the need for strategic sustainment planning interventions that target EBP fit (i.e., fit between adopted EBPs and agency target population, fit between EBP and therapist preferences and career goals) and support therapist self-efficacy in delivering EBPs.
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http://dx.doi.org/10.1007/s10488-019-00987-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237196PMC
March 2020

"I wouldn't know where to start": Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults.

Autism 2020 05 1;24(4):919-930. Epub 2019 Nov 1.

University of Pennsylvania, USA.

Lay Abstract: Most autistic adults struggle with mental health problems, such as anxiety and depression. However, they often have trouble finding effective mental health treatment in their community. The goal of this study was to identify ways to improve community mental health services for autistic adults. We interviewed 22 autistic adults with mental healthcare experience, 44 community mental health clinicians (outpatient therapists, case managers, and intake coordinators), and 11 community mental health agency leaders in the United States. Our participants identified a variety of barriers to providing quality mental healthcare to autistic adults. Across all three groups, most of the reported barriers involved clinicians' limited knowledge, lack of experience, poor competence, and low confidence working with autistic adults. All three groups also discussed the disconnect between the community mental health and developmental disabilities systems and the need to improve communication between these two systems. Further efforts are needed to train clinicians and provide follow-up consultation to work more effectively with autistic adults. A common suggestion from all three groups was to include autistic adults in creating and delivering the clinician training. The autistic participants provided concrete recommendations for clinicians, such as consider sensory issues, slow the pace, incorporate special interests, use direct language, and set clear expectations. Our findings also highlight a need for community education about co-occurring psychiatric conditions with autism and available treatments, in order to increase awareness about treatment options.
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http://dx.doi.org/10.1177/1362361319882227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192780PMC
May 2020

: Pilot outcomes of a community adaptation of an intervention for autism risk.

Autism 2020 04 29;24(3):617-632. Epub 2019 Sep 29.

Child and Adolescent Services Research Center (CASRC), USA.

This study reports child and family outcomes from a community-based, quasi-experimental pilot trial of that is a parent-mediated, naturalistic, developmental behavioral intervention for children with or at-risk for autism spectrum disorder developed through a research-community partnership. Community early interventionists delivered either ( = 10) or Usual Care ( = 9) to families based on Part C assigned provider. Twenty-five families participated, with children averaging 22.76 months old ( = 5.06). Family and child measures were collected at intake, after 3 months of service, and after a 3-month follow-up. Results indicate significantly greater improvements in positive parent-child interactions for than usual care families, as well as large, but non-significant, effect sizes for families in children's social and communication skills.
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http://dx.doi.org/10.1177/1362361319878080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102932PMC
April 2020

Factors Influencing the Use of Cognitive-Behavioral Therapy with Autistic Adults: A Survey of Community Mental Health Clinicians.

J Autism Dev Disord 2019 Nov;49(11):4421-4428

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Cognitive-behavioral therapy (CBT) can improve anxiety and depression in autistic adults, but few autistic adults receive this treatment. We examined factors that may influence clinicians' use of CBT with autistic adults. One hundred clinicians completed an online survey. Clinicians reported stronger intentions (p = .001), more favorable attitudes (p < .001), greater normative pressure (p < .001), and higher self-efficacy (p < .001) to start CBT with non-autistic adults than with autistic adults. The only significant predictor of intentions to begin CBT with clients with anxiety or depression was clinicians' attitudes (p < .001), with more favorable attitudes predicting stronger intentions. These findings are valuable for designing effective, tailored implementation strategies to increase clinicians' adoption of CBT for autistic adults.
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http://dx.doi.org/10.1007/s10803-019-04156-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814555PMC
November 2019

In-Session Caregiver Behaviors during Evidence-Based Intervention Delivery for Children with ASD in Community Mental Health Services.

Evid Based Pract Child Adolesc Ment Health 2019 7;4(1):55-71. Epub 2019 Feb 7.

Department of Psychiatry, University of California, San Diego.

An Individualized Mental Health Intervention for ASD, ("AIM HI"), is a collaborative, caregiver-mediated and child-directed intervention for reducing challenging behaviors in children with autism spectrum disorder developed for delivery in community mental health programs. Using observational data from AIM HI sessions, the present study characterized the occurrence of two types of in-session caregiver behaviors: expressed concerns (i.e., ) and participation engagement (i.e., ). Further analyses examined cultural differences in caregiver behaviors and associations between caregiver behaviors and clinician adherence. Participants included 39 caregiver-clinician dyads enrolled in a community effectiveness trial of AIM HI. Video recordings from 107 sessions during the first two months of treatment were coded for in-session caregiver behaviors and clinician adherence. Results indicated that expressed concerns were observed in 47% of sessions. When controlling for household income, Latinx caregivers were rated lower for and demonstrated lower participation engagement behaviors in session compared with non-Latinx White caregivers, suggesting that cultural factors may impact verbal engagement in sessions. Finally, , , and participation engagement were positively associated with clinician adherence. Findings suggest that some expressed concerns and participation engagement behaviors may be indicators of positive caregiver engagement in the context of a collaborative intervention, and lower levels of such caregiver engagement may actually impede clinicians' delivery of intensive evidence-based intervention in routine care.
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http://dx.doi.org/10.1080/23794925.2019.1565500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602542PMC
February 2019

Utilizing Community-Based Implementation Trials to Advance Understanding of Service Disparities in Autism Spectrum Disorder.

Glob Pediatr Health 2019 13;6:2333794X19854939. Epub 2019 Jun 13.

University of California, San Diego, Child and Adolescent Services Research Center, Autism Discoverty Institute at Rady Children's Hospital, San Diego, CA, USA.

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http://dx.doi.org/10.1177/2333794X19854939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566472PMC
June 2019

Factors Associated With Caregiver Attendance in Implementation of Multiple Evidence-Based Practices in Youth Mental Health Services.

Psychiatr Serv 2019 09 4;70(9):808-815. Epub 2019 Jun 4.

Department of Psychology, University of California, Los Angeles (Wright, Lau); Child and Adolescent Services Research Center, Department of Psychiatry, University of California, San Diego (Brookman-Frazee).

Objective: The implementation of evidence-based practices (EBPs) in community mental health settings for youths has consistently yielded weakened effects compared with controlled trials. There is a need to feasibly measure the quality of large-scale implementation efforts to inform improvement targets. This study used therapist-reported caregiver attendance in treatment sessions as a quality indicator in the community implementation of EBPs.

Methods: Data were collected from therapists practicing in agencies contracted to provide publicly funded children's mental health services following a system-driven implementation of multiple EBPs. Community therapists (N=101) provided information about youth clients (N=267) and psychotherapy sessions (N=685). Multivariable binomial logistic regressions were conducted to examine associations between caregiver attendance and therapist factors (e.g., licensure status, education), youth factors (e.g., gender, age), and the type of EBP delivered.

Results: Caregiver attendance occurred in 42% of sessions. The following factors were associated with increased odds of caregiver attendance: younger client age, male sex of client, externalizing presenting problem, and delivery of an EBP that prescribes caregiver attendance at all sessions. Caregiver attendance at sessions targeting trauma or externalizing disorders appeared to explain the differences between boys and girls in levels of caregiver engagement.

Conclusions: Overall, the patterns of actual caregiver attendance appeared consistent with empirically informed practice parameters for involvement of caregivers in treatment. Still, the rates of caregiver attendance in externalizing-focused sessions were suboptimal, and the gender difference in these rates-which clearly disfavored girls-suggests targeted areas for quality improvement. Potential reasons for these quality gaps are discussed.
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http://dx.doi.org/10.1176/appi.ps.201800443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718317PMC
September 2019

Research Community Collaboration in Observational Implementation Research: Complementary Motivations and Concerns in Engaging in the Study of Implementation as Usual.

Adm Policy Ment Health 2020 03;47(2):210-226

Department of Psychiatry, University of California, San Diego, CA, USA.

Implementation research is dominated by studies of investigator-driven implementation of evidence-based practices (EBPs) in community settings. However, systems of care have increasingly driven the scale-up of EBPs through policy and fiscal interventions. Research community partnerships (RCPs) are essential to generating knowledge from these efforts. Interviews were conducted with community stakeholders (system leaders, program managers, therapists) involved in a study of a system-driven implementation of multiple EBPs in children's mental health services. Findings suggest novel considerations in initial engagement phases of an RCP, given the unique set of potentially competing and complementary interests of different stakeholder groups in implementation as usual.
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http://dx.doi.org/10.1007/s10488-019-00939-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7055481PMC
March 2020

A mixed methods study to adapt and implement integrated mental healthcare for children with autism spectrum disorder.

Pilot Feasibility Stud 2019 28;5:51. Epub 2019 Mar 28.

1Department of Psychiatry, University of California, San Diego, La Jolla USA.

Background: There is a critical need for effective implementation of integrated healthcare systems for children with autism spectrum disorder (ASD). Children with ASD have many service needs, including the need to access effective mental healthcare, given high rates of co-occurring psychiatric conditions. Pediatric primary care is an ongoing point of healthcare that is well positioned to identify mental health concerns and facilitate linkage to mental health services for children with ASD. However, identifying mental health problems in children with ASD by primary care providers is complex, subject to being overlooked and may significantly vary based on primary care organizational characteristics. Efforts targeting integrated primary-mental healthcare implementation require a tailored approach for children with ASD.

Methods: This mixed methods, community-partnered study will apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011; Moullin et al., in press) to adapt and implement an integrated care model, "Access to Tailored Autism INtegrated Care" (ATTAIN), in pediatric practices within three diverse healthcare settings for children ages 4-18 years. Key inner context factors from the Exploration, Preparation, and Implementation phases of the EPIS framework will guide three objectives of this study: (1) to identify targets to improve mental health screening and linkage to mental health services in primary care for children with ASD, (2) to adapt integrated care procedures to facilitate identification of mental health problems and linkage to evidence-based care for children with ASD, and (3) to examine feasibility, acceptability, and uptake of the adapted integrated mental healthcare model through a pilot study in pediatric primary care.

Discussion: Improving integrated mental healthcare for children with ASD could have a significant public health impact on mental healthcare access, child clinical outcomes, and reduction in healthcare costs. Results from this mixed methods study will inform selection of implementation strategies to conduct larger-scale implementation of tailored integrated mental healthcare for children with ASD that will ultimately help to address the high unmet mental health needs for these children.
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http://dx.doi.org/10.1186/s40814-019-0434-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438023PMC
March 2019

Leadership profiles associated with the implementation of behavioral health evidence-based practices for autism spectrum disorder in schools.

Autism 2019 11 27;23(8):1957-1968. Epub 2019 Mar 27.

University of Washington, USA.

Implementation of evidence-based practice (EBP) for autism spectrum disorder (ASD) in the education system is a public health priority. Leadership is a critical driver of EBP implementation but little is known about the types of leadership behaviors exhibited by school leaders and how this influences the context of EBP implementation, particularly for students with ASD. The objectives of this study were to determine (1) the leadership profiles of principals involved in EBP implementation for students with ASD and (2) how these leadership profiles related to school characteristics and implementation climate. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to guide the design and analysis of this study. Participants (n = 296) included principals, teachers, and classroom support staff. They provided demographic information and completed the Multifactor Leadership Questionnaire and Implementation Climate Scale. Using latent profile analysis, a three-pattern solution was identified: (6% of sample), (23% of sample), and (71% of sample). Principals in schools with higher proportions of students with an individualized education program were more likely to be classified as than . The group was associated with more positive implementation climate than the or groups. Findings suggest that leadership behaviors rated by principals and their staff involved in implementation of common autism EBPs can be meaningfully clustered into three discernible profiles that are shaped by organizational context and linked to strategic implementation climate. Our study findings have implications for leadership training and service delivery in schools by underscoring the critical nature of school leadership during implementation of EBPs for children with autism and the interplay between specific leadership behaviors and strategic implementation climate.
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http://dx.doi.org/10.1177/1362361319834398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6764916PMC
November 2019

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.

Adm Policy Ment Health 2020 03;47(2):176-187

Department of Psychiatry, University of California, Davis MIND Institute, Sacramento, CA, USA.

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.
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http://dx.doi.org/10.1007/s10488-019-00931-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756990PMC
March 2020
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