Therapist Anxious Distress and Avoidance of Implementing Time-Out.

Therapist anxious distress when delivering child mental health treatment has been understudied as a factor that contributes to the underuse of some evidence-based interventions (EBIs), such as time-out for children with disruptive behaviors. This study investigated therapist anxious avoidance of time-out using a three-part, vignette-based survey design. Therapists (n = 198) read a vignette of an in-session time-out and reported on their personal anxious distress and likelihood of discontinuing the implementation of time-out. Therapists also provided open-ended descriptions of challenges to delivering time-out. Therapists reported moderate anxious distress at time points 1 and 2 and lower anxious distress at time 3 when the time-out had resolved. Most therapists endorsed some avoidance of time-out. Binomial logistic regression analyses indicated that increased anxious distress corresponded with an increased probability of avoiding time-out delivery in the future. Qualitative reports expanded on challenges to implementing time-out. Findings suggest the importance of addressing therapist anxious distress when implementing children's mental health treatments.

Adapting to Unprecedented Times: Community Clinician Modifications to Parent-Child Interaction Therapy during COVID-19.

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice that effectively prevents and treats child disruptive behaviors and child physical maltreatment and reduces parenting stress. PCIT was adapted for telehealth delivery, internet-delivered PCIT (iPCIT), before the COVID-19 pandemic but was not widely implemented until the rapid transition to telehealth during stay-at-home orders. To understand how clinicians adapted PCIT during COVID-19, we followed up on a previous study investigating community clinician adaptations of PCIT pre-COVID-19 using the Lau et al. (2017) Augmenting and Reducing Framework. Clinicians (N = 179) who responded to the follow-up survey and reported delivering PCIT remotely completed a quantitative measure of adaptations at both time points (Fall 2019; Summer 2020) to assess how adaptations to PCIT changed following lockdown measures. Clinicians (n = 135) also provided qualitative descriptions of adaptations made early in the COVID-19 pandemic. Clinicians in the full sample were 74.3% Non-Hispanic White and 14% Latinx. Most clinicians had a master's degree (66.5%), were licensed (80.4%), and were PCIT-certified (70.4%). Paired samples t-tests showed that clinicians reported similar levels of augmenting t(179) = -0.09, p=.926) and reducing adaptations t(179) = -0.77, p=.442) at both time points. Unlike quantitative findings, qualitative findings indicated that clinicians described engaging in many types of adaptations in response to the pandemic. Clinicians discussed engaging in augmenting adaptations by extending treatment length and integrating other practices into treatment. Clinicians also discussed engaging in reducing adaptations. Implications and future directions will be discussed.

A Mixed-Methods Study of Clinician Adaptations to Parent-Child Interaction Therapy - What about Culture?

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice (EBP) for young children with challenging behaviors. PCIT has been adapted to treat varying presentations and culturally diverse families. Although efforts have been made to disseminate PCIT into community settings, which often serve clinically complex, socio-culturally diverse, and marginalized communities, barriers to disseminating adapted models remain. An alternative strategy to understanding how to increase access to appropriately adapted PCIT is to learn from community clinicians' practice-based adaptations to meet their clients' diverse needs related to clinical presentation, culture, and language. This mixed-method study investigated community clinician adaptations of PCIT. Clinicians (N = 314) were recruited via PCIT listservs to complete a survey collecting background information, and adaptations to PCIT. Most clinicians had a master's degree (72.1%), were licensed (74.2%), and were PCIT-certified (70.7%). Qualitative interviews were conducted with a purposeful sample of 23 community clinicians, who were 39% Spanish-speaking, were 30% Latinx, and 30% reported serving a ≥50% Latinx clientele. Clinicians reported engaging in adaptations aimed at augmenting PCIT more extensively than adaptations involving removing core components. Themes from qualitative interviews converged with quantitative findings, with clinicians most frequently describing augmenting adaptations, and highlighted reasons for adapting PCIT. Clinicians primarily augmented treatment to address clients' clinical presentations. Clinicians rarely adapted treatment specifically for culture, but when mentioned, clinicians discussed tailoring idioms and phrases to match clients' culture for Spanish-speaking clients. Implications for training PCIT clinicians in intervention adaptations will be discussed.

How do Lay Health Worker Engage Caregivers? A Qualitative Study to Enhance Equity in Evidence-Based Parenting Programs.

Engaging caregivers in their children's mental health treatment is critical for delivering high quality, evidence-based care, particularly for young children with externalizing behaviors. Lay health workers (LHWs), including peer providers and promotoras de salud, have been identified as important workforces in addressing structural and stigma-related barriers to engagement in mental health services. Importantly, research has suggested that LHWs may be integral in efforts to address engagement disparities in evidence-based behavioral parent training programs (BPTs) for Latinx caregivers. The purpose of the study was to understand how different LHW workforces engage caregivers within their usual services, in order to inform strategies that improve access to and engagement in BPTs. Qualitative interviews were conducted with two different LHW workforces: volunteer LHWs (i.e., promotoras de salud) (n = 14), who were part of a community-embedded network, and paid LHWs (i.e., parent support partners, home visitors) (n = 9) embedded within children's mental health agencies. Participants were predominately Latinx (79%) and female (96%). Qualitative analyses revealed three primary themes related to engagement strategies used by LHWs to address barriers to care: 1.) Building Trust, 2.) Empowerment, 3.) Increasing Access. Although the majority of themes and sub-themes were consistent across the two LHW workforces, agency-embedded LHWs often discussed having the means to provide resources through their organizations, whereas community-embedded LHWs discussed acting as a bridge to services by providing information and conducting outreach. Findings have implications for partnering with different workforces of LHWs to increase equity in access to BPTs.

Intervention and Implementation Characteristics to Enhance Father Engagement: A Systematic Review of Parenting Interventions.

In recent years, the prevalence rates of children's mental health disorders have increased with current estimates identifying that as many as 15-20% of children meet criteria for a mental health disorder. Unfortunately, the same robust parenting interventions which have long targeted some of the most common and the most treatable child concerns (e.g., externalizing, disruptive behavior, and aggression) have also shown consistently low rates of father engagement. This persistent issue of engagement comes in the wake of an increasingly large body of literature which highlights the unique positive contributions fathers make to children and families when they are engaged in parenting interventions. As the role fathers play in families shifts to become more inclusive of childcare responsibilities and less narrowly defined by financial contributions, it becomes increasingly important to understand how best to engage fathers in interventions that aim to enhance parenting efficacy and family outcomes such as coparenting. The current review examined intervention (e.g., format and setting) and implementation characteristics (e.g., training and agency-level changes) associated with father engagement. Particular attention is paid to studies which described father-specific engagement strategies (e.g., inviting fathers directly, father-only groups, and adapting intervention to incorporate father preferences). A total of 26 articles met inclusion criteria after screening and full-text review. Results indicate that father engagement (i.e., initiating treatment) remains low with 58% of studies either not reporting father engagement or having engagement rates below 50%. More than two-thirds of studies did not include specific father engagement strategies. Those that did focused on changes to treatment format (e.g., including recreational activities), physical treatment setting (e.g., in-home and school), and reducing the number of sessions required for father participation as the most common father-specific engagement strategies. Some studies reported efforts to target racially and ethnically diverse fathers, but review results indicated most participants identified as Non-Hispanic White. Interventions were largely standard behavioral parent training programs (e.g., PCIT and PMT) with few exceptions (e.g., COACHES and cultural adaptations), and very few agencies or programs are systematically making adjustments (e.g., extended clinic hours and changes to treatment format) to engage fathers. Recommendations for future directions of research are discussed including the impact of differential motivation on initial father engagement in treatment, the importance of continuing to support diverse groups of fathers, and the potential for telehealth to address barriers to father engagement.

Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary.

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

Improving the Quality of Children's Mental Health Care with Progress Measures: A Mixed-Methods Study of PCIT Therapist Attitudes.

Progress measures are an evidence-based technique for improving the quality of mental health care, however, clinicians rarely incorporate them into treatment. Research into how measure type impacts clinician preference has been recommended to help improve measure implementation. Parent-Child Interaction Therapy (PCIT) is an assessment-driven treatment that serves as an ideal intervention through which to investigate measure preferences given its routine use of two types of assessments, a behavioral observation (the Dyadic Parent-Child Interaction Coding System) and a parent-report measure (the Eyberg Child Behavior Inventory). This study investigated PCIT therapist attitudes towards progress measures used within PCIT and children's mental health treatment generally. A mixed-method (QUAN + QUAL) study design examined PCIT therapist attitudes towards two types of progress measures and measures used in two contexts (PCIT and general practice). Multi-level modeling of a survey distributed to 324 PCIT therapists identified predictors of therapist attitudes towards measures, while qualitative interviews with 23 therapists expanded and clarified the rationale for differing perceptions. PCIT therapists reported more positive attitudes towards a behavioral observation measure, the DPICS, than a parent-report measure, the ECBI, and towards measures used in PCIT than in general practice. Clinician race/ethnicity was significantly related to measure-specific attitudes. Qualitative interviews highlighted how perceptions of measure reliability, type of data offered, ease of use, utility in guiding sessions and motivating clients, and embeddedness in treatment protocol impact therapist preferences. Efforts to implement progress monitoring should consider preferences for particular types of measures, as well as how therapists are trained to embed measures in treatment.