Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery.

OBJECTIVE: This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes. METHOD: Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery. RESULTS: At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05). CONCLUSIONS: Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Systematic review: emotion dysregulation and challenging behavior interventions for children and adolescents on the autism spectrum with graded key evidence-based strategy recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Misalignment in Community Mental Health Leader and Therapist Ratings of Psychological Safety Climate Predicts Therapist Self-Efficacy with Evidence-Based Practices (EBPs).

Therapist self-efficacy in delivering evidence-based practices (EBPs) is associated with implementation outcomes, including adoption and sustainment in community mental health settings. Inner context organizational climate, including psychological safety, can proximally shape therapist learning experiences within EBP implementation. Psychologically safe environments are conducive to learning behaviors including taking risks, admitting mistakes, and seeking feedback. Organization leaders are instrumental in facilitating psychological safety, but may have differing perspectives of organizational climate than front-line therapists. Discrepant leader and therapist views of psychological safety may have independent associations with therapist EBP learning and implementation outcomes over and above average therapist perceptions of climate. This study examined survey data from 337 therapists and 123 leaders from 49 programs contracted to deliver multiple EBPs within a study examining determinants of sustainment within a large system-driven implementation. Both leaders and therapists completed measures of psychological safety climate and therapists reported on their self-efficacy in delivering multiple EBPs in children's mental health services. Polynomial regression and response surface analysis models were conducted to examine the associations of therapist and leader reports of psychological safety and therapist EBP self-efficacy. Greater discrepancies between leader and therapist reports of psychological safety, in either direction, were associated with lower therapist EBP self-efficacy. Alignment in leader and therapist views of psychological safety climate may impact EBP implementation outcomes. Strategies for improving alignment in perceptions and priorities among organizational members can be included in organizational implementation interventions and may represent unexamined implementation mechanisms of action.

Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year.

PURPOSE: In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS: To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS: The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION: Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.

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.

Training Community Therapists in AIM HI: Individual Family and Neighborhood Factors and Child/Caregiver Outcomes.

OBJECTIVE: Publicly funded mental health services play an important role in caring for children with mental health needs, including children with autism spectrum disorder (ASD). This study assessed the associations between individual family- and neighborhood-level sociodemographic factors and baseline family functioning and long-term outcomes when community therapists were trained to deliver An Individualized Mental Health Intervention for ASD (AIM HI). METHOD: Participants included 144 children with ASD (ages 5 to 13 years; 58.3% Latinx) and their caregivers whose therapists received AIM HI training within a cluster-randomized effectiveness-implementation trial in publicly funded mental health services. Sociodemographic strain (e.g., low income, less education, single-parent status, minoritized status) was coded at the individual family and neighborhood level, and caregivers rated caregiver strain at baseline. Child interfering behaviors and caregiver sense of competence were assessed at baseline and 6-, 12- and 18-months after baseline. RESULTS: Higher caregiver strain was associated with higher intensity of child behaviors (B = 5.17, p < .001) and lower caregiver sense of competence (B = -6.59, p < 001) at baseline. Child and caregiver outcomes improved over time. Higher caregiver strain (B = 1.50, p < .001) and lower family sociodemographic strain (B = -0.58, p < .01) were associated with less improvements in child behaviors. Lower caregiver strain (B = -2.08, p < .001) and lower neighborhood sociodemographic strain (B = -0.51, p < .01) were associated with greater improvements in caregiver sense of competence. CONCLUSIONS: Findings corroborate the importance of considering both family and neighborhood context in the community delivery of child-focused EBIs. TRIAL REGISTRATION: Clinical Trials NCT02416323.

Patterns of Child Mental Health Service Utilization Within a Multiple EBP System of Care.

The current study (1) characterizes patterns of mental health service utilization over 8 years among youth who received psychotherapy in the context of a community implementation of multiple evidence-based practices (EBPs), and (2) examined youth-, provider- and service-level predictors of service use patterns. Latent profile analyses were performed on 5,663,930 administrative claims data furnished by the county department of mental health. Multinomial logistic regression with Vermunt's method was used to examine predictors of care patterns. Based on frequency, course, cost, and type of services, three distinct patterns of care were identified: (1) Standard EBP Care (86.3%), (2) Less EBP Care (8.5%), and (3) Repeated/Chronic Care (5.2%). Youth age, ethnicity, primary language, primary diagnosis and secondary diagnosis, provider language and provider type, and caregiver involvement and service setting were significant predictors of utilization patterns. Although the majority of youth received care aligned with common child EBP protocols, a significant portion of youth (13.7%) received no evidence-based care or repeated, costly episodes of care. Findings highlight opportunities to improve and optimize services, particularly for youth who are adolescents or transition-aged, Asian-American/Pacific Islander, Spanish-speaking, or presenting with comorbidities.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps.

PURPOSE OF REVIEW: This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population. RECENT FINDINGS: Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

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

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).

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.

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

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.

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

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.

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

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.

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

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 (n = 8,626), youth clients (n = 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.

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

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.

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

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.

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

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.

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

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.

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

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.

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.