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.

Caregiver Participation Engagement in Child Mental Health Prevention Programs: a Systematic Review.

Prevention programs are a key method to reduce the prevalence and impact of mental health disorders in childhood and adolescence. Caregiver participation engagement (CPE), which includes caregiver participation in sessions as well as follow-through with homework plans, is theorized to be an important component in the effectiveness of these programs. This systematic review aims to (1) describe the terms used to operationalize CPE and the measurement of CPE in prevention programs, (2) identify factors associated with CPE, (3) examine associations between CPE and outcomes, and (4) explore the effects of strategies used to enhance CPE. Thirty-nine articles representing 27 unique projects were reviewed. Articles were included if they examined CPE in a program that focused to some extent on preventing child mental health disorders. There was heterogeneity in both the terms used to describe CPE and the measurement of CPE. The majority of projects focused on assessment of caregiver home practice. There were no clear findings regarding determinants of CPE. With regard to the impact of CPE on program outcomes, higher levels of CPE predicted greater improvements in child and caregiver outcomes, as well as caregiver-child relationship quality. Finally, a small number of studies found that motivational and behavioral strategies (e.g., reinforcement, appointment reminders) were successful in promoting CPE. This review highlights the importance of considering CPE when developing, testing, and implementing prevention programs for child mental health disorders. Increased uniformity is needed in the measurement of CPE to facilitate a better understanding of determinants of CPE. In addition, the field would benefit from further evaluating strategies to increase CPE as a method of increasing the potency of prevention programs.

Improving social-emotional competence in internationally adopted children with the Attachment and Biobehavioral Catch-up intervention.

Children adopted internationally experience adverse conditions prior to adoption, placing them at risk for problematic social-emotional development. The Attachment and Biobehavioral Catch-up (ABC) intervention was designed to help internationally adoptive parents behave in ways that promote young children's social-emotional competence. Participants included 131 parent-child dyads randomly assigned to receive either ABC (n = 65) or a control intervention (n = 66). In addition, 48 low-risk biologically related parent-child dyads were included as a comparison group. At follow-up assessments conducted when children were 24 to 36 months old, internationally adopted children who received the ABC intervention had higher levels of parent-reported social-emotional competence than children who received a control intervention. In addition, observational assessments conducted when children were 48 and 60 months of age showed that internationally adopted children who received ABC demonstrated higher social-emotional competence than children who received a control intervention. Adopted children who received the control intervention, but not the ABC intervention, displayed more difficulties with social-emotional competence than low-risk children. Finally, postintervention parent sensitivity mediated the effect of ABC on observed child social-emotional competence in parent interactions, controlling for preintervention parent sensitivity. These results demonstrate the efficacy of a parenting-focused intervention in enhancing social-emotional competence among children adopted internationally.

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.

Promoting Compliance in Children Referred to Child Protective Services: A Randomized Clinical Trial.

Early experiences of maltreatment have long-term negative effects on children's compliance. This randomized clinical trial examined whether a brief preventative intervention (Attachment and Biobehavioral Catch-up; ABC) was effective in enhancing compliance in children who had been referred to Child Protective Services. Participants included 101 parent-child dyads who received either ABC or a control intervention when children were infants (M = 9.4 months old, SD = 6.1). When children were approximately 36 months old (M = 38.5, SD = 3.0), ABC children demonstrated significantly better compliance than control children. Further, parent sensitivity, measured 1 month post intervention when children were, on average, 18.4 months old (SD = 6.9) partially mediated the effect of ABC on child compliance at 36 months old.

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.

Defining and Predicting High Cost Utilization in Children's Outpatient Mental Health Services.

Little is known about high-cost service users in the context of youth outpatient mental health, despite the fact that they account for a large proportion of overall mental healthcare expenditures. A nuanced understanding of these users is critical to develop and implement tailored services, as well as to inform relevant policies. This study aims to characterize high-cost service users by examining demographic factors, diagnoses, and service type use. Administrative service use data were extracted from a large County Department of Behavioral Health Services database. Latent profile analyses suggest a four-profile solution primarily distinguished by youth age and diagnostic complexity. Study findings have implications for defining high-cost service users and key targets for efforts aiming to improve outcomes for these youth.

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.

Enhancing the language development of toddlers in foster care by promoting foster parents' sensitivity: Results from a randomized controlled trial.

Young children in foster care are at increased risk for problematic language development, making early intervention a critical tool in enhancing these children's foundational language abilities. This study examined the efficacy of an early preventative intervention, Attachment and Biobehavioral Catch-up for Toddlers (ABC-T), in improving the receptive vocabulary abilities of toddlers placed in foster care. All the children had been removed from their biological parents' care and placed into foster care. When children were between 24 and 36 months old, foster parents were contacted by research staff and consented to participate. Parents were randomly assigned using a random number generator to receive either ABC-T (n = 45), which aimed to promote sensitive parenting for children who have experienced early adversity, or a control intervention (n = 43). Foster children's receptive vocabulary skills were assessed post-intervention using the Peabody Picture Vocabulary Test, Third Edition, when children were between 36 and 60 months old. Children whose foster parents received ABC-T demonstrated more advanced receptive vocabulary abilities than children whose foster parents received the control intervention. The positive effect of ABC-T on foster children's receptive vocabulary was mediated by increases in foster parents' sensitivity during parent-child interactions. Trial registration: ClinicalTrials.gov NCT01261806.

Longitudinal associations between low morning cortisol in infancy and anger dysregulation in early childhood in a CPS-referred sample.

Children who experience early adversity are at increased risk for developing psychopathology, and dysfunction of the hypothalamic pituitary adrenal (HPA) axis is a possible mechanism conferring this risk. This study sought to characterize the association between morning cortisol during different developmental periods and deficits in children's emotion regulation, a core feature of many psychological disorders. Morning cortisol was collected at two time points (i.e., during infancy, M = 13.0 months old, and during early childhood, M = 36.8 months old) from 120 children with histories of child protective services (CPS) involvement. Children completed a lab visit during early childhood (M = 38.6 months old) that involved an observational measure of anger regulation. Results showed that low morning cortisol during infancy, but not early childhood, predicted increased anger dysregulation during early childhood. These results highlight the importance of developmental timing in assessing the effects of HPA axis functioning and suggest that low cortisol during infancy is a risk factor for later emotion regulation difficulties.

Enhancing executive functioning among toddlers in foster care with an attachment-based intervention.

Young children in foster care often experience adversity, such as maltreatment and lack of stability in early caregiving relationships. As a result, these children are at risk for a range of problems, including deficits in executive functioning. The Attachment and Biobehavioral Catch-up for Toddlers (ABC-T) intervention was designed to help foster parents behave in ways that promote the development of young children's emerging self-regulatory capabilities. Participants included 173 parent-toddler dyads in three groups: foster families that were randomly assigned to receive either the ABC-T intervention (n = 63) or a control intervention (n = 58), as well as low-risk parent-toddler dyads from intact families (n = 52). At a follow-up conducted when children were approximately 48 months old, children's executive functioning abilities were assessed with the attention problems scale of the Child Behavior Checklist (Achenbach & Rescorla, 2000) and a graded version of the Dimensional Change Card Sort developed for preschoolers (Beck, Schaefer, Pang, & Carlson, 2011). Results showed that foster children whose parents received the ABC-T intervention and low-risk children never placed in foster care had fewer parent-reported attention problems and demonstrated greater cognitive flexibility during the Dimensional Change Card Sort than foster children whose parents received the control intervention. These results indicate that an attachment-based intervention implemented among toddlers in foster care is effective in enhancing children's executive functioning capabilities.

Attachment states of mind among internationally adoptive and foster parents.

The first aim of the current study was to examine the latent structure of attachment states of mind as assessed by the Adult Attachment Interview (AAI) among three groups of parents of children at risk for insecure attachments: parents who adopted internationally (N = 147), foster parents (N = 300), and parents living in poverty and involved with Child Protective Services (CPS; N = 284). Confirmatory factor analysis indicated the state of mind rating scales loaded on two factors reflecting adults' preoccupied and dismissing states of mind. Taxometric analyses indicated the variation in adults' preoccupied states of mind was more consistent with a dimensional than a categorical model, whereas results for dismissing states of mind were indeterminate. The second aim was to examine the degree to which the attachment states of mind of internationally adoptive and foster parents differ from those of poverty/CPS-referred parents and low-risk parents. After controlling for parental age, sex, ethnicity, and socioeconomic status, (a) internationally adoptive parents had lower scores on the dismissing dimension than the sample of community parents described by Haltigan, Leerkes, Supple, and Calkins (2014); (b) foster parents did not differ from community parents on either the dismissing or the preoccupied AAI dimension; and (c) both internationally adoptive and foster parents had lower scores on the preoccupied dimension than poverty/CPS-referred parents. Analyses using the traditional AAI categories provided convergent evidence that (a) internationally adoptive parents were more likely to be classified as having an autonomous state of mind than low-risk North American mothers based on Bakermans-Kranenburg and van IJzendoorn's (2009) meta-analytic estimates, (b) the rates of autonomous states of mind did not differ between foster and low-risk parents, and

Outside the Clinic Door: How Neighborhood Sociodemographic Disadvantage is Associated with Community Therapist Secondary Traumatic Stress and Emotional Exhaustion.

Therapists serving families with high rates of trauma exposure in community mental health clinics face the potential risk of experiencing secondary traumatic stress and emotional exhaustion, both of which pose barriers for the implementation and sustainment of evidence-based practices. Previous research documents negative effects of living in socioeconomic disadvantaged neighborhoods on child development but has not examined the effects of working in these neighborhoods on therapist well-being. The current study merges publicly available data, administrative claims data on mental health services, and therapy survey data to 1) identify associations between neighborhood sociodemographic disadvantage and two community therapist well-being constructs, specifically secondary traumatic stress and emotional exhaustion; and 2) examine potential clinic- and therapist-level explanatory factors in the associations between neighborhood sociodemographic disadvantage and therapist well-being. A cumulative risk index approach was applied to calculate neighborhood sociodemographic disadvantage. Greater neighborhood sociodemographic disadvantage was significantly associated with higher levels of therapist secondary traumatic stress (B=.09, p<.05) but not emotional exhaustion. Because therapists in higher risk neighborhoods face higher secondary traumatic stress levels, additional research is needed to better understand how these therapists can be best supported; thus, supporting families receiving treatment and implementation of evidence-based practices.

Organizational factors associated with community therapists' self-efficacy in EBP delivery: The interplay between sustainment leadership, sustainment climate, and psychological safety.

Background: Inner context organizational factors proximally shape therapist experiences with evidence-based practice (EBP) implementation and may influence therapist self-efficacy, which has been linked to sustained use of EBPs in community mental health settings. Research has primarily focused on constructs such as implementation leadership and climate. However, the effects of such factors may depend upon other inner context dimensions, such as psychological safety. Psychologically safe environments are conducive to taking risks, speaking up about problems, and requesting feedback and may promote therapist self-efficacy during implementation. This study examines whether organizational sustainment leadership and sustainment climate relate to therapist EBP self-efficacy only under conditions of psychological safety. Methods: Data were collected from 410 clinicians in 85 programs during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. Therapists reported on their organization's sustainment leadership, sustainment climate, psychological safety, and their own self-efficacy in delivering specific EBPs. Multilevel regression analyses were conducted to account for nested data structure. Results: Among program-level variables, sustainment leadership and psychological safety both significantly predicted therapist self-efficacy. However, there were no significant interactions between program-level sustainment climate and psychological safety. Exploratory post-hoc analyses revealed a significant interaction between program-level sustainment leadership and therapist-level perceptions of psychological safety such that that the conditional effect of psychological safety on EBP self-efficacy was significant at high levels of sustainment leadership, but not at low or average levels. Conclusion: We noted independent links between sustainment leadership, organizational psychological safety and therapists feelings of confidence and mastery with EBPs. Therapists' individual perceptions of psychological safety were linked to self-efficacy only in programs with high sustainment leadership. Thus, sustainment leadership and psychological safety may both represent implementation intervention targets, but it may not be critical to assess for perceptions of psychological safety before deploying organizational leadership strategies.Plain language abstract Therapist self-efficacy is a therapist's belief that they are capable, knowledgeable, and skilled enough to deliver evidence-based practices (EBPs), and is thought to promote improved clinical and implementation outcomes, such as therapists' sustained use of EBPs. Conditions within community mental health organizations may influence therapists' sense of EBP self-efficacy. Leaders' support and expectations for EBP implementation, and collective staff perceptions about the organization's climate to support EBPs are linked to positive therapist attitudes and EBP adoption. However, less is known about how these implementation-specific organizational factors associated with therapist EBP self-efficacy in the long-term, and how this may depend on general workplace conditions. Specifically, psychologically safe environments - where therapists feel safe taking risks such as asking questions, admitting mistakes, and trying new skills - may be needed to promote self-efficacy when therapists are tasked with learning and using complex multi-component EBP innovations. The current study tested the prediction that leader-driven and program-wide focus on EBP sustainment may promote therapist EBP self-efficacy only in organizations where conditions for learning are psychologically safe. Our findings confirmed that fostering strong sustainment focused leadership and psychologically safe environments may each be important for increasing therapists' EBP self-efficacy. The model results suggested that individual therapist perceptions of psychological safety were more strongly related to EBP self-efficacy in programs with greater implementation leadership. Findings suggest the importance of increasing EBP leadership behavior to fully potentiate other facilitating conditions for therapist learning in the sustainment phase of EBP implementation initiatives.

Intervening With Attachment and Biobehavioral Catch-Up to Reduce Behavior Problems Among Children Adopted Internationally: Evidence From a Randomized Controlled Trial.

Children who have been adopted internationally often exhibit persistent behavior problems. The current study assessed the efficacy of the Attachment and Biobehavioral Catch-up intervention (ABC; Dozier & Bernard, 2019) for reducing behavior problems in 122 children adopted internationally. Behavior problems were measured via parent-report using the Brief Infant Toddler Social Emotional Assessment at a pre-intervention visit and after the intervention when children were between 18 and 36 months. Children's behavior problems were also observed using the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS) after the intervention when children were 48 and 60 months. Parents who received ABC reported fewer child behavior problems than parents who received the control intervention immediately after the intervention through 1.5 years post-intervention. Additionally, children whose parents received ABC exhibited fewer behavior problems within the parent context of the DB-DOS when they were 48 months old (2 years post-intervention) than children whose parents received the control intervention. There were no significant intervention effects on children's observed behavior problems within the examiner contexts. These results support the efficacy of ABC in reducing behavior problems among children adopted internationally. Trial registration: ClinicalTrials.gov NCT00816621.

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

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) 2022 APA, all rights reserved).

Strategies that Promote Therapist Engagement in Active and Experiential Learning: Micro-Level Sequential Analysis.

Therapists' active learning increases treatment fidelity, but research is needed on supervisory strategies to engage therapists in active learning. This study used sequential analysis to examine consultant behaviors associated with increased and decreased probability of eliciting therapists' active learning. The study included 162 consultation sessions from 27 community therapists implementing Attachment and Biobehavioral Catch-up. Consultants' client discussion, information provision, and modeling were associated with reduced likelihood of active learning. Consultants' questions, engagement in active learning strategies, use of video, and silence were associated with greater likelihood of therapist active learning. These findings inform supervisors' attempts to encourage active learning.

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.

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, Autism Engagement Strategies and Active Teaching Strategies, while strategies used by usual care therapists grouped onto a broader single factor, General Strategies. Among usual care therapists, General Strategies were related to an increase in child behavior problems, whereas for AIM HI therapists, Active Teaching Strategies 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.