Perspectives on Financing Strategies for Evidence-Based Treatment Implementation in Youth Mental Health Systems.

BACKGROUND: Evidence-based treatments (EBTs) are critical to effectively address mental health problems among children and adolescents, but costly for mental health service agencies to implement and sustain. Financing strategies help agencies overcome cost-related barriers by obtaining financial resources to support EBT implementation and/or sustainment. AIMS: We sought to (i) understand how youth mental health system decision-makers involved with EBT implementation and sustainment view key features (e.g., relevance, feasibility) that inform financing strategy selection and (ii) compare service agency, funding agency, and intermediary representative perspectives. METHOD: Two surveys were disseminated to 48 representatives across U.S. youth mental health service agencies, funding agencies, and intermediaries who were participating in a larger study of financing strategies. Quantitative and qualitative data were gathered on 23 financing strategies through quantitative ratings and open-ended responses. Data were analyzed using descriptive statistics and rapid content analysis. RESULTS: The financing strategies rated as most relevant include braided funding streams, contracts for EBTs, credentialing/rostering providers, fee-for-service reimbursement (regular and increased), and grant funding. All other strategies were unfamiliar to 1/3 to 1/2 of participants. The six strategies were rated between somewhat and quite available, feasible, and effective for EBT sustainment. For sustaining different EBT components (e.g., delivery, materials), the mix of financing strategies was rated as somewhat adequate. Qualitative analysis revealed challenges with strategies being non-recurring or unavailable in representatives' regions. Ratings were largely similar across participant roles, though funding agency representatives were the most familiar with financing strategies. DISCUSSION: Despite the breadth of innovative financing strategies, expert representatives within the youth mental health services ecosystem had limited knowledge of most options. Experts relied on strategies that were familiar but often did not adequately support EBT implementation or sustainment. These findings underscore more fundamental issues with under-resourced mental health systems in the U.S.; financing strategies can help agencies navigate EBT use but must be accompanied by larger-scale system reforms. Limitations include difficulties generalizing results due to using a small sample familiar with EBTs, high agreement as a potential function of snowball recruiting, and limited responses to the open-ended survey questions. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Although EBTs have been found to effectively address mental health problems in children and adolescents, available strategies for financing their implementation and sustainment in mental health systems are insufficient. This constraint prevents many children and adolescents from receiving high-quality services. IMPLICATIONS FOR HEALTH POLICIES: Financing strategies alone cannot solve systematic issues that prevent youth mental health service agencies from providing EBTs. Policy changes may be required, such as increased financial investment from the U.S. government into mental health services to support basic infrastructure (e.g., facility operations, measuring outcomes). IMPLICATIONS FOR FURTHER RESEARCH: Future work should examine expert perspectives on EBT financing strategies in different contexts (e.g., substance use services), gathering targeted feedback on financing strategies that are less well known, and exploring topics such as strategic planning, funding stability, and collaborative decision-making as they relate to EBT implementation and sustainment.

Understanding Initial and Sustained Engagement of Spanish-Speaking Latina Mothers in the Legacy for Children Program™: A Qualitative Examination of a Group-Based Parenting Program.

Culturally congruent parenting programs delivered during early childhood have the potential to support diverse families. Legacy for Children™ (Legacy) is a group-based prevention program designed to promote child development by reinforcing sensitive, responsive mother-child relationships, building maternal self-efficacy, and fostering peer networks of support among mothers living in poverty (Perou et al., 2012). The Legacy program was translated and culturally adapted for Spanish-speaking Latina mothers and their infants (hereafter referred to as Latina mothers) with a feasibility trial conducted to determine the cultural congruency of the adaptation. Feasibility results were positive with no previous studies validating the adapted Legacy Spanish language program (Legacy Spanish). The current manuscript focuses on understanding factors of engagement of the culturally adapted model. Specifically, we examined the factors that were perceived to have enhanced or hindered both initial and sustained engagement in the adapted Legacy Spanish program for Latina mothers. Individual interviews were conducted with Latina mothers (N=26) who attended the Legacy Spanish program. We used a template approach within NVivo 11© software to identify broad themes in Latina mothers' responses. Themes emerged regarding the importance of using home-based recruitment strategies and pairing verbal information with written brochures to foster initial engagement. Sustained engagement themes focused on the provision of support from other Latina mothers in the Legacy group and the relationships with the group leaders. Having group leaders who were perceived as genuine, kind, positive, "good" at teaching, and persistent emerged as themes that facilitated initial and ongoing engagement. Barriers to engagement centered primarily on logistics rather than characteristics of the program itself. Thus, Latina mothers attributed importance to aspects of the curriculum, logistics, and implementation with respect to program engagement. Application of similar engagement strategies could enhance the success of early childhood parenting programs and linkages with early educational programming.

Parent engagement in an original and culturally adapted evidence-based parenting program, Legacy for Children™.

Legacy for Children™ (Legacy) is an evidence-based program focused on promoting sensitive, responsive parenting for socioeconomically disadvantaged families. Legacy has recently been culturally and linguistically adapted for Spanish-monolingual Latino families and is being piloted in partnership with an early childhood education program. We conducted a mixed methods study to identify barriers and facilitators to engagement, using program monitoring data sources from both participant and group leader perspectives. We conducted qualitative analyses of open-ended data to identify distinct barriers (e.g., employment challenges, health-related challenges and appointments) and facilitators (e.g., other mothers in group, interest in program topics) to engagement that emerged across English and Spanish language curriculum versions; curriculum-specific barriers and facilitators were also documented. We interpret these findings in light of quantitative data on measures of engagement, showing that participants in the Spanish curriculum evidenced comparable levels of parent-group leader relationship quality relative to the English group, and higher levels of parent's group support/connectedness and overall satisfaction. These results offer promising considerations for optimizing families' engagement in parenting programs in the context of early care and education settings.

Legado para los Niños™ (Legado) es un programa basado en la evidencia que se centra en promover una crianza sensible y susceptible para familias con desventajas socioeconómicas. Recientemente, Legado se ha adaptado cultural y lingüísticamente para familias Latinas en las que sólo se habla español, y está siendo puesto en práctica experimental en asociación con un programa de educación en la temprana niñez. Llevamos a cabo un estudio con una variedad mixta de métodos para identificar obstáculos y promotores para ser incluidos usando recursos de información de la supervisión del programa provenientes de las perspectivas tanto de participantes como de líderes de grupo. Realizamos análisis cuantitativos de información no limitada de antemano para identificar diferentes obstáculos (v.g. dificultades de empleo, dificultades y citas relacionadas con la salud) y promotores (v.g. otras madres en el grupo, interés en los temas del programa) para ser incluidos los cuales surgieron a lo largo de las versiones curriculares del inglés y del español; también se documentaron los obstáculos y promotores relacionados con el currículo específico. Interpretamos estos resultados a la luz de la información cuantitativa sobre medidas de participación, mostrando que los participantes en el currículo en español demostraron comparables niveles de calidad de la relación progenitor-líder de grupo en relación con el grupo de inglés, y más altos niveles de apoyo del grupo a los progenitores y satisfacción en general. Estos resultados ofrecen consideraciones prometedoras para lograr una óptima participación de las familias en programas de crianza en el contexto de escenarios de cuidado y educación tempranos.

Le programme Legacy for ChildrenTM (Legacy) est un programme factuel se concentrant sur la promotion d'une parentage sensible et réactif pour des familles de milieu socioéconomique défavorisé. Legacy a récemment été culturellement et linguistiquement adapté aux familles Latino américaines, en espagnol, et se trouve testé en partenariat avec un programme éducatif de la petite enfance. Nous avons procédé à une étude au moyen de méthodes mixtes afin d'identifier les barrières qui existent et freinent l'engagement, ainsi que ce qui facilite l'engagement, en utilisant des sources de données d'évaluation du programme à la fois de la perspective des participants et du leader de groupe. Nous avons fait des analyses qualitatives de données ouvertes afin d'identifier des barrières précises (i.e. les défis du chômage, les défis liés à la santé et aux rendez-vous) et les aspects facilitateurs (i.e. autres mères dans le groupe, intérêt pour les sujets du programme) pour l'engagement qui ont émergé au travers des deux versions, la version en anglais et la version en espagnol. Les barrières tenant au curriculum et aux facilitateurs ont aussi été répertoriées. Nous avons interprété ces résultats à la lumière de données quantitatives sur des mesures d'engagement, montrant que les personnes participant au curriculum espagnol faisaient preuve de niveaux comparables de qualité de la relation parent-meneur de groupe que le groupe anglais, et de niveaux plus élevés de soutien/connexion et de satisfaction générale du groupe parent. Ces résultats offrent des considérations prometteuses pour l'optimisation de l'engagement des familles dans des programmes de parentage dans le contexte du soin précoce et de l'éducation de la petite enfance.

Qualitative Analysis of Administrator, Provider, and Stakeholder Views on the Costs and Benefits of a Treatment for Problematic Sexual Behavior of Youth.

Evidence-based treatment for youth with problematic sexual behavior (PSB) has the potential for a broad range of costs and benefits, raising the importance of querying its public health impact. This qualitative study examined the impact of treatment for youth with PSB through content analysis of interviews (N = 57) with service agency administrators, treatment providers, and professional stakeholders in communities where recent implementation of interventions for youth with PSB had occurred. Interviewees emphasized multi-level impacts of the program on families (e.g., knowledge, well-being), communities (e.g., public safety, education), and public agencies (e.g., caseloads, stress). Implications for comprehensively evaluating the impact of PSB interventions are discussed.

Depression in Latina mothers: Examining the roles of acculturation, enculturation, social support, and family resources.

OBJECTIVES: Previous findings on the relationship between acculturation and depression have been mixed, such that acculturation has been demonstrated as a protective factor, risk factor, and neutral factor for depressive symptomology. The current study sought to clarify this association by examining the roles of acculturation and enculturation (retention of traditional values and practices) on depression while incorporating contextual variables such as social support and resource adequacy. METHOD: This study utilized archived data from 308 Latina mothers who participated in a randomized clinical trial evaluating the effectiveness of a home-based child maltreatment prevention model that was culturally adapted for a midwestern Latino/a community. RESULTS: Findings from this study suggest that although enculturation was negatively associated with depression, this impact was no longer significant when multiple factors were examined. Rather, increased family resources and social support were related to fewer depressive symptoms. Furthermore, social support and family resources both demonstrated mediating roles between the relation of acculturation and depression. Family resources also mediated the relation between enculturation and depression. CONCLUSIONS: Findings highlight the importance of assessing access to resources and interpersonal connections when working with Latina mothers experiencing depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A qualitative investigation of policy for youth with problematic sexual behavior.

AIMS: Community management of youth with problematic sexual behavior (PSB) is complex. Public policies and service practices have historically utilized adult-focused approaches with limited research outcomes. This descriptive case study aimed to address this gap by documenting current PSB policies and policy reforms for community-based management systems. METHOD: Semi-structured interviews with 219 professionals from eight urban and rural communities throughout the United States served as the primary data source for the study. The three-stage Framework Method was used to guide the data analysis process. RESULTS: This study covered three areas: context of policy development, attitudes, and perceptions of policy for youth with PSB, and existing policy and policy reform initiatives. CONCLUSION: Findings support benefits of collaborative multidisciplinary teams that cross agency policies and procedures on management of cases involving youth with PSB. Implications for practitioners, policymakers, and community members are discussed.

A Qualitative Evaluation of Engagement and Attrition in a Nurse Home Visiting Program: From the Participant and Provider Perspective.

Beginning parenting programs in the prenatal and early postnatal periods have a large potential for impact on later child and maternal outcomes. Home-based parenting programs, such as the Nurse Family Partnership (NFP), have been established to help address this need. Program reach and impact is dependent on successful engagement of expecting mothers with significant risks; however, NFP attrition rates remain high. The current study qualitatively examined engagement and attrition from the perspectives of NFP nurses and mothers in order to identify mechanisms that enhance service engagement. Semi-structured interviews were conducted in focus groups composed of either engaged (27 total mothers) or unengaged (15 total mothers) mothers from the NFP program. NFP nurses (25 total nurses) were recruited for individual semi-structured interviews. Results suggest that understanding engagement in the NFP program requires addressing both initial and sustained engagement. Themes associated with enhanced initial engagement include nurse characteristics (e.g., flexible, supportive, caring) and establishment of a solid nurse-family relationship founded on these characteristics. Factors impacting sustained engagement include nurse characteristics, provision of educational materials on child development, individualized services for families, and available family support. Identified barriers to completing services include competing demands and lack of support. Findings of this study have direct relevance for workforce planning, including hiring and training through integrating results regarding effective nurse characteristics. Additional program supports to enhance parent engagement may be implemented across home-based parenting programs in light of the current study's findings.

Childhood Injury Prevention: Predictors of Home Hazards in Latino Families Enrolled in SafeCare®.

Objective: This archival project (a) examined potential risk and protective factors for hazards in the homes of Spanish-speaking immigrant Latino families and (b) provided an independent examination of the SafeCare®+ Home Safety module adapted for Latino families at high risk for child neglect. Methods: The sample comprised 92 Latina caregivers of young children enrolled in SafeCare®+. Results: Results of the negative binomial regression model of predictors of home hazards before the Home Safety module found none of the factors were significant. The longitudinal analysis with a negative binomial model found significant effects both during (b = -0.905, p < .001) and after (b = -2.118, p < .001) the intervention. Depression was negatively associated with the number of hazards (b = -0.026, p < .05, ß = -.1858). Conclusions: Support for application of SafeCare®+ Home Safety module to prevent access to hazards for Latino children was found.

A qualitative study of cultural congruency of Legacy for Children™ for Spanish-speaking mothers.

In recognition of the need to reach more families, the Legacy for Children™ (Legacy) program was translated and culturally adapted for Spanish-speaking Hispanic mothers and their infants. This study examined the cultural adaptations and logistical supports needed for successful implementation with Spanish-speaking mothers. The research team used purposive techniques to sample Hispanic bi-lingual providers (N = 14) and supervisors (N = 5) of local home-based parenting programs (Healthy Families, Parents as Teachers, and SafeCare®). The goal of the study was to determine from providers and supervisors the social validity (satisfaction, relevancy, importance, and acceptability of the intervention) and cultural congruency of the adapted Legacy curriculum. Researchers conducted a qualitative analysis of the transcriptions using a template approach within NVivo 10 software to identify broad themes within focus group data. Overall, results indicated many positive aspects of the Legacy program including content, approach, pace, topics, structure, social engagement, and straightforward curriculum language. Emergent themes from the focus groups included best practices in identifying, recruiting, and approaching Hispanic mothers, as well as key engagement strategies. Recommended revisions of the adapted Legacy curriculum focused on enhancing visual and auditory supplements, making minor improvements to lower the reading level, and reducing barriers to attendance. Implications for cultural adaptation of parenting programs are discussed.

Pilot evaluation of the Fiscal Mapping Process for sustainable financing of evidence-based youth mental health treatments: A comparative case study analysis.

Background: Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies. Supports are needed that can guide service agencies in accessing sustainable funding for EBTs. We conducted a pilot evaluation of the Fiscal Mapping Process, an Excel-based strategic planning tool that helps service agency leaders identify and coordinate financing strategies for their EBT programs. Method: Pilot testing of the Fiscal Mapping Process was completed with 10 youth mental health service agencies over a 12-month period, using trauma-focused cognitive-behavioral therapy or parent-child interaction therapy programs. Service agency representatives received initial training and monthly coaching in using the tool. We used case study methods to synthesize all available data (surveys, focus groups, coaching notes, document review) and contrast agency experiences to identify key findings through explanation building. Results: Key evaluation findings related to the process and outcomes of using the Fiscal Mapping Process, as well as contextual influences. Process evaluation findings helped clarify the primary use case for the tool and identified the importance-and challenges-of engaging external collaborators. Outcome evaluation findings documented the impacts of the Fiscal Mapping Process on agency-reported sustainment capacities (strategic planning, funding stability), which fully explained reported improvements in outcomes (extent and likelihood)-although these impacts were incremental. Findings on contextual factors documented the influence of environmental and organizational capacities on engagement with the tool and concerns about equitable impacts, but also the view that the process could usefully generalize to other EBTs. Conclusions: Our pilot evaluation of the Fiscal Mapping Process was promising. In future work, we plan to integrate the tool into EBT implementation initiatives and test its impact on long-term sustainment outcomes across various EBTs, while increasing attention to equity considerations.

Pilot-Testing a Tool for Planning the Sustainable Financing of Youth Mental Health Treatments that Work Plain Language Summary Youth mental health treatments that work must be consistently available to improve youth mental health in our communities, but funding for these treatments is often limited and hard to access. Youth mental health service agencies need tools that can help guide them in accessing sustainable funding for evidence-based treatments. We developed the Fiscal Mapping Process, an Excel-based strategic planning tool for planning sustainable financing of youth mental health treatment programs, and conducted a 1-year pilot-testing evaluation with 10 youth mental health service agencies. We used case study methods to compare and contrast agency experiences with using the tool, related to the process, outcomes, and contextual influences on using the Fiscal Mapping Process. Key findings included clarification of the ideal characteristics of contributors and treatment programs for using the tool; initial confirmation that the tool can improve agency-reported capacities for sustaining treatments that work and long-term sustainment outlooks, although these impacts were incremental; and documentation of the influence of environmental and organizational capacities on engagement with the tool, concerns about equitable impacts, and user views that the process could be applied to a wide range of treatment models. In summary, our pilot evaluation of the Fiscal Mapping Process showed that this tool is promising for supporting the financial sustainment of treatments that work in youth mental health services. In future research, we plan to incorporate the tool into real-world training initiatives with mental health service agencies, test its impact on long-term sustainment across a variety of treatment models, and incorporate attention to equity considerations.

Comparison of children's advocacy center responses to harmful sexual behavior among siblings: An international perspective.

BACKGROUND: Harmful sexual behavior (HSB) is sexual behavior exhibited by children and adolescents that is developmentally inappropriate and/or harmful or abusive towards themselves or others. Victims of children with HSB are commonly siblings. Multiple professionals may be involved in cases of youth HSB involving siblings, which places Children's Advocacy Centers (CACs) in a key position to directly address intrafamilial HSB. Approximately 25% of all cases seen at CACs in the U.S. are youth-initiated HSB. However, no known research has examined how CAC professionals approach decision-making and response to intrafamilial and sibling HSB, particularly across regions and cultures. OBJECTIVES: To examine the perspectives of professionals from three separate CACs in Israel, eastern U.S., and southwestern U.S. regarding their decision-making and response process for sibling HSB. PARTICIPANTS AND SETTING: Thirty-seven multidisciplinary team members from the three CACs, including representatives from child welfare, law enforcement, family advocacy, mental health, and the court system, among others, participated in the study. METHODS: Participants completed focus groups that asked them to discuss how their system would respond to a vignette case. Dedoose was used for thematic analysis. RESULTS: Using qualitative thematic analysis, results indicate all sites perceived sibling HSB as a family crisis, and they prioritized establishing safety and providing therapeutic interventions. Differences across sites were on how to establish safety and when to use legal actions. CONCLUSIONS: The study draws attention to the influences that formal policy and community contexts have on CAC decision-making, particularly around the availability of evidence-based treatments and caregiver engagement.

How does COVID-19 impact intrafamilial child sexual abuse? Comparison analysis of reports by practitioners in Israel and the US.

BACKGROUND: There is consensus in child sexual abuse (CSA) literature that intrafamilial child sexual abuse (IFCSA) has a tremendous impact on children and families while simultaneously creating challenges for practitioners. COVID-19 impacted countries worldwide and generated a global crisis resulting in impacts on daily life, however, it's effect on IFCSA is unknown. OBJECTIVE: This study aimed to compare professional perspectives and experiences working with IFCSA with respect to the context of the COVID-19 pandemic within the United States and Israel. PARTICIPANTS AND SETTING: Participants were therapeutic, child welfare and legal professionals, who provided services to children involved in IFCSA. METHODS: This qualitative cross-cultural comparative study analyzes professional experiences of IFCSA during COVID-19 based on an open-ended questionnaire answered online, with 37 responses from the US and 23 responses from Israel. RESULTS: Findings reveal mostly negative changes in the dynamics of IFCSA families during COVID-19, including financial, environmental, and emotional hardships, as well as some positive changes in the relationships among family members. In terms of professional interventions, concerns were raised that COVID-19 has been detrimental to the disclosure of IFCSA, with plummeting child abuse reports. Further, risk and benefits of transferring to internet based or telephonic therapeutic interventions were shared. CONCLUSIONS: Governmental and community efforts are needed to develop a safety net of protective factors to reduce IFCSA risks and increase resiliency during the COVID-19 pandemic and future global crises. Moreover, enhanced strategies to accessing and supporting families remotely such as using technology could improve identification and response to IFCSA.

The Role of Social Support on Depression Among Vulnerable Caregivers Reporting Bidirectional Physical Violence.

Intimate partner violence (IPV) is a public health concern found across genders, socioeconomic strata, cultures, and ethnicities. While IPV is traditionally examined from either the victim or initiator role, it is also important to consider relationships in which both partners experience and demonstrate violence. The current study examined the relation between IPV chronicity and depression among 403 female caregivers with young children. Specifically, the current study examined the association between bidirectional IPV and depression. Furthermore, the impact of social support on depression levels among those caregivers was assessed. Results suggest that of those couples who experienced violence, bidirectional IPV was reported significantly more frequently than unidirectional IPV only. No significant differences in depression were found between those reporting bidirectional versus unidirectional IPV. Among those involved in bidirectional IPV, having greater social support was associated with significantly lower depression levels. Findings suggest that both initiation and experiences of IPV should be assessed among caregivers of vulnerable children. The potential impact of social support was also identified in this study. Clinicians may consider assessing family violence broadly, including bidirectional IPV, particularly among parents of young children with other adverse life conditions. Development and sustainment of healthy relationships through social support may facilitate adjustment for the caregivers.

Sustaining Treatment for Youth with Problematic Sexual Behavior: Administrator and Stakeholder Perspectives Following Implementation.

This study examines administrator and stakeholder perspectives on factors influencing the sustainability of Problematic Sexual Behavior Cognitive Behavioral Therapy (PSB-CBT). After initial implementation of PSB-CBT, qualitative interviews (N = 42) on the sustainability of services were conducted with treatment program administrators (n = 10) and community stakeholders (n = 32) from six sites across the USA. Interviewees discussed key facilitators and barriers for sustainability and identified the following factors as impacting the sustainability of PSB-CBT: public relations, policy, inter-agency collaboration, funding, and workforce issues. Results were overall consistent with the EPIS (Exploration, Preparation, Implementation, Sustainment) model for implementation in public service sectors, but proposed modifications are also noted. Findings underscore the value of qualitative research in identifying best practices for sustaining valuable therapeutic interventions. The authors argue that future efforts to sustain evidence-based interventions, especially those dealing with sensitive topics around which misinformation and stigma are associated, should prioritize public relations (i.e., outreach, education) in addition to the intervention.

Barriers to Accessing Treatment Services: Child Victims of Youths with Problematic Sexual Behavior.

Child sexual abuse (CSA) remains a significant public health problem. Although the deleterious effects on the child victims could be mitigated through evidence-based interventions, victims often fail to be identified and receive clinical assessment and therapy services, particularly when they have been victimized by another youth. Given that at least a third of CSA cases are committed by another youth, understanding the process of identifying and addressing the needs of CSA victims of youth is the focus of the present study. Factors impacting services for child victims of youths with problematic sexual behavior (PSB) were examined through qualitative interviews (N = 226) with mental health agency administrators, direct service providers, and community stakeholders from eight geographically diverse communities across the United States. Responses focused on macro and micro level barriers to the identification and service provision for child victims of PSB of youths. Implications for clinicians and policymakers are discussed, along with strategies to enhance access and provision of services to meet the needs of the child victims.

Enhancing Early Engagement (E3) in mental health services training for children's advocacy center's victim advocates: feasibility protocol for a randomized controlled trial.

BACKGROUND: Child maltreatment is a major public issue in the United States, yet most children affected by abuse or neglect never engage in evidence-based practices (EBP) for child mental health. Children's Advocacy Centers (CACs') are uniquely situated to serve as Family Navigators who connect children impacted by maltreatment to appropriate EBPs. In fact, the CAC position of Victim Advocate mirrors the Mental Health Family Navigator national initiative. METHODS: The feasibility study protocol is to develop, implement, and evaluate web-based and consultative training for Victim Advocates to enhance early engagement in services (E3 training). The interactive web-based training embeds key targets of knowledge and skills related to family engagement, trauma, and EBP services. Participating CACs were randomized to E3 webinar-based training, E3 webinar plus consultation, or delayed training. The project will test the E3 training's impact on key mechanisms of change (e.g., knowledge, skills) to improve rates of screening, referral, and access to EBP services. The feasibility of implementing the training program and differential impact and costs by level of training will be examined. DISCUSSION: The overarching goal of this project is to test the feasibility of training that is readily implemented through CACs and examine the mechanisms for improving early engagement and, ultimately, child, and adolescent mental health outcomes. Results and cost findings will be used to plan a large-scale comprehensive, mixed-methods hybrid type II effectiveness-implementation and cost-effectiveness trial of family navigator E3 training. If outcomes are positive, considerable infrastructure exists to support the scale-up and sustainability of E3 training nationwide, by embedding the training in national CAC training protocols. TRIAL REGISTRATION: NCT04221633 DATE AND VERSION IDENTIFIER: March 25, 2021; Vers. 1.0 (original); September 11, 2021; Vers 2.0 (revision); October 29, 2021; Vers. 3.0 (revision).

Economic value of community-based services for problematic sexual behaviors in youth: A mixed-method cost-effectiveness analysis.

BACKGROUND: Problematic sexual behavior in youth represents a significant public health problem in need of evidence-based treatments. Unfortunately, such treatments are not available in most communities. OBJECTIVE: This study used a mixed quantitative-qualitative approach to investigate the economics of the implementation of Problematic Sexual Behavior - Cognitive-Behavioral Therapy (PSB-CBT), an evidence-based treatment for problem sexual behaviors in youth. PARTICIPANTS AND SETTING: Youth (N = 413) participated in PSB-CBT at six program sites in youth service agencies across the United States. METHOD: We used cost-effectiveness ratios (CERs) to compare the direct and indirect costs of PSB-CBT to self- and caregiver-reported youth clinical outcomes (i.e., problem sexual behavior as well as secondary behavioral health problems). CERs represented the cost of achieving one standard unit of change on a measure (i.e., d = 1.0). The design and interpretation of those quantitative analyses were informed by qualitative themes about program costs and benefits that were derived from interviews with 59 therapists, administrators, and stakeholders. RESULTS: CERs (i.e., $ per SD) were $1,772 per youth for problem sexual behavior and ranged from $2,867 to $4,899 per youth for secondary outcomes. These quantitative results, considered alongside the qualitative perspectives of interviewees, suggested that the implementation of PSB-CBT was cost-effective. The results were robust to uncertainty in key parameters under most, but not all, conditions. CONCLUSIONS: The results have important implications for decisions made by administrators, policymakers, and therapists regarding use of community-based approaches to address problematic sexual behavior of youth.

Early identification of youth with problematic sexual behavior: A qualitative study.

BACKGROUND: Early intervention efforts designed for youth with problematic sexual behavior (PSB) have strong promise. Prompt identification of youth with PSB is critical to ensuring early intervention and effective response. OBJECTIVE: The current study explored the complexities of how PSB of youth is identified in the community. SETTING: A qualitative semi-structured interview approach was utilized to explore the perceptions and experiences of community members involved in cases of youth with PSB. PARTICIPANTS: Participants included 100 community members from eight geographically diverse locations in the United States. METHOD: Themes involving identification of PSB were classified by qualitative analyses, beginning with thematic analysis followed by focused coding. RESULTS: Results indicated multiple pathways for the identification of youth with PSB involving a variety of professionals and agencies. Victim disclosure and witnessing the PSB were the most common identification pathways, with caregivers and school personnel the most common initial identifiers. Once identified, cases were reported to child welfare, law enforcement, and/or behavioral health agencies. Complications due to unclear response pathways and fears held by caregivers were notable. CONCLUSIONS: Developmentally appropriate, evidence-informed policies and procedures for the identification of and response to PSB in youth within and across professions would facilitate a public health response to for prevention and early responses to PSB of youth.

A scoping review of strategies for financing the implementation of evidence-based practices in behavioral health systems: State of the literature and future directions.

Background: Increased availability of evidence-based practices (EBPs) is essential to alleviating the negative public health and societal effects of behavioral health problems. A major challenge to implementing and sustaining EBPs broadly is the limited and fragmented nature of available funding. Method: We conducted a scoping review that assessed the current state of evidence on EBP financing strategies for behavioral health based on recent literature (i.e., post-Affordable Care Act). We defined financing strategies as techniques that secure and direct financial resources to support EBP implementation. This article introduces a conceptualization of financing strategies and then presents a compilation of identified strategies, following established reporting guidelines for the implementation strategies. We also describe the reported level of use for each financing strategy in the research literature. Results: Of 23 financing strategies, 13 were reported as being used within behavioral health services, 4 had potential for use, 5 had conceptual use only, and 1 was potentially contraindicated. Examples of strategies reported being used include increased fee-for-service reimbursement, grants, cost sharing, and pay-for-success contracts. No strategies had been evaluated in ways that allowed for strong conclusions about their impact on EBP implementation outcomes. Conclusion: The existing literature on EBP financing strategies in behavioral health raises far more questions than answers. Therefore, we propose a research agenda that will help better understand these financing strategies. We also discuss the implications of our findings for behavioral health professionals, system leaders, and policymakers who want to develop robust, sustainable financing for EBP implementation in behavioral health systems. Plain language abstract: Organizations that treat behavioral health problems (mental health and substance use) often seek to adopt and use evidence-based practices (EBPs). A challenge to adopting EBPs broadly is the limited funding available, often from various sources that are poorly coordinated with one another. To help organizations plan effectively to adopt EBPs, we conducted a review of recent evidence (i.e., since the passage of the 2010 Affordable Care Act) on strategies for financing EBP adoption in behavioral health systems. We present definitions of 23 identified strategies and describe each strategy's reported (in the research literature) level of use to fund EBP adoption in behavioral health services. Of the 23 financing strategies, 13 strategies had evidence of use, 4 had potential for use, 5 had conceptual use only, and 1 was potentially contraindicated. Examples of strategies with evidence of use include increased fee-for-service reimbursement, grants, cost sharing, and pay-for-success contracts. This comprehensive list of EBP financing strategies may help guide decision-making by behavioral health professionals, system leaders, and policymakers. The article also presents a research agenda for building on the current research literature by (1) advancing methods to evaluate financing strategies' effects, (2) partnering with stakeholders and decision-makers to examine promising financing strategies, (3) focusing on strategies and service systems with the greatest needs, (4) improving methods to guide the selection of financing strategies, and (5) paying greater attention to sustainable long-term financing of EBPs.

Predictors of Intrusive Sexual Behaviors in Preschool-Aged Children.

Intrusive sexual behaviors (ISBs) are a specific type of problematic sexual behavior characterized by the invasive nature of the acts (e.g., touching others' private parts, attempting intercourse; Friedrich, 1997). The limited amount of research on ISBs has focused on sexual abuse history as the primary predictor. However, Friedrich, Davies, Feher, and Wright (2003) found that ISBs in children up to age 12 were related to four broad conceptual factors: (a) exposure to sexual content, (b) exposure to violent behavior, (c) family adversity, and (d) child vulnerabilities. The current study sought to replicate Friedrich's study using a clinical sample of 217 preschool-aged children (ages two to six). Results supported variables from within the child vulnerabilities construct (externalizing behaviors, ßEXT = 0.032, p = 0.001), post-traumatic stress disorder (PTSD) criteria met (ßPTSD = 0.177, p = 0.02), and an inverse relationship with age (ßAGE = -0.206, p = 0.024). These results highlight the importance of considering childhood behavioral patterns and reactivity to traumatic events as correlates of ISBs in young children.