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.

A Natural Helper Intervention to Address Disparities in Parent Child-Interaction Therapy: A Randomized Pilot Study.

OBJECTIVE: Parent-child interaction therapy (PCIT) is an effective intervention to address child externalizing behaviors. However, disparities in access and retention are pervasive, which relate to the availability of PCIT in low-income communities, inadequate workforces to provide culturally appropriate care, and distrust in services due to systemic discrimination. This study incorporated natural helpers who had been trained as community health workers into PCIT delivery to improve disparities in engagement and outcomes. METHOD: Families from three low-income, predominately Latino/a/x and Black neighborhoods in Miami qualified for services if they had a child aged 2-8 with clinically elevated externalizing behaviors. Families were randomly assigned into either Standard-PCIT group (N = 30 families; 80% boys, 57% Latino/a/x, 27% Black) or a PCIT plus Natural helper (PCIT+NH) group (N = 51 families; 66% boys, 76% Latino/a/x, 18% Black). Families in the PCIT+NH group received home visits and support addressing barriers to care from a natural helper. Path analyses within an intention-to-treat framework examined group-differences in treatment engagement, child behavior, and parenting skills and stress. RESULTS: Families in both groups demonstrated large improvements in child externalizing behavior, caregiver stress, and parenting skills from pre-to-post-treatment. Externalizing behavior improved significantly more in the PCIT+NH group compared to the Standard-PCIT group. There were no significant group differences in parenting skills or caregiver stress. Though differences in engagement were not significant, the PCIT+NH group had a small effect on treatment retention. CONCLUSIONS: Natural helpers may help to address structural barriers that systematically impact communities of color, apply treatment in naturalistic environments, and promote improved treatment outcomes.

Adapting Community Health Worker Care Models to Advance Mental Health Services Among LGBTQ Youth.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth of color experience high rates of mental health disorders, yet they experience challenges to accessing mental health services. Community health worker (CHW) models of care have potential to promote equitable mental health services among LGBTQ youth. Our aim was to understand how CHW models could be adapted to better support LGBTQ youth of color in accessing mental health services. Semi-structured qualitative interviews were conducted with LGBTQ youth of color (n = 16), caregivers of LGBTQ youth (n = 11), and CHWs (n = 15) in Massachusetts and California. Interviews were coded by 8 members of the research team. A Rapid Qualitative Analysis was conducted to identify themes. Caregivers, youth, and CHWs all endorsed the value of CHW models for this population. They also almost universally suggested multiple adaptations are needed for the model to be effective. Four main categories of themes emerged related to intervention adaptations: (1) Why adaptations are needed for LGBTQ youth, (2) Who should serve as CHWs providing care, (3) How CHWs should be trained, and (4) What content needs to be included in the intervention. Broadly, findings suggest the relevance of having CHW models for LGBTQ youth of color to address stigma and discrimination experienced, access to culturally and linguistically relevant services, and the need for caregiver support of LGBTQ youth. CHWs need increased training in these areas.

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.

Lay Health Workers Engaging Latino Fathers: A qualitative study.

Behavioral Parent Training programs (BPTs) are evidence-based interventions that have been shown to be effective when implemented in various contexts and with different racial/ethnic minority families. Despite evidence showing their effectiveness within the Latinx community, disparities in access to BPTs still persist. In addition, fathers continue to show low rates of attendance and engagement despite evidence suggesting positive outcomes for the youth and family when fathers are involved in BPT treatment. Lay health workers (LHWs), community members without specialized metal health training that often live in the communities they serve, have been identified as engagement specialists that are uniquely positioned to reduce racial/ethnic disparities in access to services. The current study utilized a qualitative approach to examine this workforce's perspectives on engaging Latino fathers in parenting services in children's mental health. Qualitative themes revealed that LHWs have generally positive attitudes towards engaging Latino fathers in parenting interventions (i.e., benefits to parent-child relationship) despite experiencing barriers to engagement (e.g., culturally defined gender roles, fathers being less likely to ask for help). Themes also elucidate various engagement strategies that LHWs use to engage fathers in treatment (e.g., adapting treatment setting). Considerations for future LHW trainings and workforce development are discussed with a focus on how to incorporate cultural values in the use of father-engagement strategies.

A Preliminary Analysis of Parent-Child Interaction Therapy Plus Natural Helper Support to Increase Treatment Access and Engagement for Low-Income Families of Color.

Disparities in care for low-income children of color call for innovative culturally and linguistically responsive solutions to better engage marginalized populations in evidence-based interventions. In partnership with a community organization, the addition of natural helper support as an adjunct to Parent-Child Interaction Therapy (PCIT+NH) was examined as a strategy to increase recruitment, engagement, and retention in PCIT for families historically unreached by a university-based clinic. Natural helpers provided home-based skills practice and support for forty-two families whose parents were more racially and linguistically diverse and had lower income and lower caregiver education than the typical population served by the same program (i.e., program population). Families who received PCIT+NH had comparable or higher rates of engagement and improvements in clinical outcomes (i.e., decreased child externalizing and internalizing behaviors, increased child compliance, decreased caregiver stress, increased caregiver parenting skills) relative to the program population. Furthermore, higher doses of natural helper support were associated with higher rates on most measures of treatment engagement (i.e., treatment completion, completion of the Child Directed Interaction phase of treatment, PCIT sessions, homework in the Parent Directed Interaction phase of treatment), with the exception of homework in the Child Directed Interaction phase of treatment and overall session attendance rate. Next steps for testing the treatment engagement and clinical outcome effects of the PCIT+NH model are discussed.

Future Directions in Lay Health Worker Involvement in Children's Mental Health Services in the U.S.

Nearly half of children meeting criteria for a mental health disorder in the United States (U.S.) do not receive the treatment they need. Unfortunately, lack of access to and engagement in mental health services can be seen at even higher rates for historically marginalized groups, including low-income, racial, and ethnic minority youth. Lay Health Workers (LHWs) represent a valuable workforce that has been identified as a promising solution to address mental health disparities. LHWs are individuals without formal mental health training who oftentimes share lived experiences with the communities that they serve. A growing body of research has supported the mobilization of LHWs to address service disparities around the globe; however, challenges persist in how to scale-up and sustain LHW models of care, with specific barriers in the U.S. In this paper, we describe LHWs' different roles and involvement in the mental health field as well as the current state of the literature around LHW implementation. We integrate the RE-AIM Framework with a conceptual model of how LHWs address disparities to outline future directions in research and practice to enhance equity in the reach, effectiveness, adoption, implementation, and maintenance of LHW models of care and evidence-based practices for historically marginalized communities within the U.S.

Therapist Experiences and Attitudes About Implementing Internet-Delivered Parent-Child Interaction Therapy During COVID-19.

It has been widely recognized that access to mental health treatment is imperative to address current and long-term stressors for children and parents during COVID-19. Internet-delivered Parent-Child Interaction Therapy (iPCIT, previously referred to as I-PCIT) is a strong model for remote service delivery during social distancing restrictions due to its empirical base. However, this treatment modality was not widely implemented before COVID-19, likely due to barriers to providing telehealth services. This mixed methods study conducted a follow-up survey to gather therapist experiences (N = 223) in delivering iPCIT during COVID-19, including qualitative data on the benefits and challenges to delivering iPCIT. The vast majority of therapists (82%) indicated that they transitioned to deliver PCIT via telehealth in response to COVID-19. PCIT caseloads decreased slightly from the first survey to the COVID-19 follow-up survey, but the racial and ethnic composition of caseloads were not significantly different between the two surveys. Of the 183 therapists who transitioned to deliver PCIT via telehealth, 82% expressed interest in continuing to provide iPCIT following the COVID-19 pandemic. Reported benefits of iPCIT included decreased barriers to access and the ability to practice skills within the naturalistic home environment. Challenges to iPCIT were primarily issues with technology as well as other logistical barriers, which could limit engagement for some families. Findings from this study may be beneficial in improving future implementation of iPCIT during and post-COVID-19.

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.

Co-Occurring Youth Profiles of Adverse Childhood Experiences and Protective Factors: Associations with Health, Resilience, and Racial Disparities.

It is important to understand racial/ethnic differences in adverse childhood experiences (ACEs), given their relationship to long-term physical and mental health, and the public health cost of the significant disparities that exist. Moreover, in order to inform interventions and promote resilience, it is critical to examine protective factors that mitigate the relationship between adversity and poor health. The current study utilized latent transition analyses (LTA) to examine co-occurring profiles of ACEs and protective factors (from school, family, and community contexts) and links to health outcomes among 30,668 Black (10.4%), Latinx (12.3%), and White youth (77.3%) ages 12-17 (52.5% male) who participated in the 2011-12 National Survey of Children's Health (NSCH). Results suggested that greater adversity was associated with worse health, while more access to protective factors was associated with better health. White youth had consistently lower endorsement of ACEs, greater access to protective factors, and better health compared to their Black and Latinx counterparts. Efforts to improve child health and racial/ethnic disparities in research and practice must consider adversity, protective factors, and the systemic inequities faced by racial/ethnic minority youth in the United States.

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.

Qualitative Reports of How and When Therapists Adapt Children's Evidence-Based Practices during Community Implementation.

This study analyzed qualitative therapist reports of adaptations to the delivery of multiple evidence-based practices (EBPs) within the context of a system-driven reform of children's community mental health services to understand how therapists adapt EBPs as well as contexts of these adaptations to identify when these adaptations are made. The study sought to complement and expand upon previous quantitative survey findings of two categories of Augmenting and Reducing/Reordering adaptations to EBPs. Data included interviews from 60 therapists (88.3% female, 61.7% Latina/o, 80.0% unlicensed) across 20 program sites in 11 mental health agencies that served racial/ethnically diverse children. Interviews were coded to identify themes surrounding the types of adaptations made and the contexts for these adaptations. The majority of therapists' qualitative descriptions of adaptations converged with the 2 broad categories in the Augmenting and Reducing/Reordering Framework, with therapists describing augmenting (e.g., modifying presentation, lengthening or extending pacing) most often, and reducing/reordering adaptations were discussed less frequently. Child and family characteristics were most frequently cited as indications prompting adaptations; however, the specific characteristics motivating adaptations differed by type. Therapists reporting using augmenting adaptations in the context of a wide range of client characteristics, whereas reducing/reordering adaptations occurred more specifically as a function of clinical presentation, family and caregiver functioning, and emergent life events. Therapists described making adaptations to improve the fit of multiple EBPs for the clients they served. Findings could have implications for implementation efforts with diverse clients served in community settings.

Trauma-Responsive Care in a Pediatric Setting: Feasibility and Acceptability of Screening for Adverse Childhood Experiences.

Adverse childhood experiences (ACEs) have demonstrable negative effects on long-term physical and mental health. Low-income and ethnic minority communities face significant disparities in exposure to ACEs. Pediatric settings offer an opportune context to identify and address ACEs, with the potential to reduce barriers in access to resources and services. The current study examined the feasibility and acceptability of screening infants and their parents for ACEs at a community medical clinic. Feasibility data indicated that 151 (92%) of the 164 unique patients that presented for well-child visits for infants (4- to 12-months) across a 13-month period were screened for infant and parent ACEs. Of these 151 patients, 47% met eligibility (infants with 1 + ACEs, parents with 2 + ACEs) deemed intermediate risk and indicated referral to prevention services. The majority of referred families (77%) accepted prevention services, including appointments with bilingual and bicultural wellness navigators who provided a cultural bridge and access to resources that could address patients' social determinants of health. Qualitative interviews with providers expand upon screening acceptability. Implications for integrated behavioral health, ACEs screening, and trauma-responsive prevention in a pediatric setting are discussed.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care.

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Predictors of Burnout among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children's Mental Health.

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.

Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review.

This systematic review evaluates efforts to date to involve community health workers (CHWs) in delivering evidence-based mental health interventions to underserved communities in the United States and in low- and middle-income countries. Forty-three articles (39 trials) were reviewed to characterize the background characteristics of CHW, their role in intervention delivery, the types of interventions they delivered, and the implementation supports they received. The majority of trials found that CHW-delivered interventions led to symptom reduction. Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities. Areas for future research as well as clinical and policy implications are discussed.

Successful Therapist-Parent Coaching: How In Vivo Feedback Relates to Parent Engagement in Parent-Child Interaction Therapy.

Although behavioral parent training is considered efficacious treatment for childhood conduct problems, not all families benefit equally from treatment. Some parents take longer to change their behaviors and others ultimately drop out. Understanding how therapist behaviors impact parental engagement is necessary to improve treatment utilization. This study investigated how different techniques of therapist in vivo feedback (i.e., coaching) influenced parent attrition and skill acquisition in parent-child interaction therapy (PCIT). Participants included 51 parent-child dyads who participated in PCIT. Children (age: M = 5.03, SD = 1.65) were predominately minorities (63% White Hispanic, 16% African American or Black). Eight families discontinued treatment prematurely. Therapist coaching techniques during the first session of treatment were coded using the Therapist-Parent Interaction Coding System, and parent behaviors were coded with the Dyadic Parent-Child Interaction Coding System, Third Edition. Parents who received more responsive coaching acquired child-centered parenting skills more quickly. Therapists used fewer responsive techniques and more drills with families who dropped out of treatment. A composite of therapist behaviors accurately predicted treatment completion for 86% of families. Although group membership was correctly classified for the treatment completers, only 1 dropout was accurately predicted. Findings suggest that therapist in vivo feedback techniques may impact parents' success in PCIT and that responsive coaching may be particularly relevant.

Views on sex and sex education among gang-involved Latino youth in the United States.

Although gang-involved Latino youth in the United States are uniquely at risk of adverse consequences from sexual behavior, little research is available that can guide those who wish to develop interventions to reduce sexual risk among these youth. To facilitate the development of effective interventions, we identified cultural and contextual factors that influence sexual behavior and sex education among gang-involved Latino youth in one U.S. community. By analyzing transcripts from interviews and focus groups with three different groups of key stakeholders--gang-experienced Latino youth, the parents of gang-experienced Latino youth, and the personnel of a program providing comprehensive human services for gang-involved Latino youth--we identified three domains to be considered in developing sexual risk-reduction interventions for gang-involved U.S. Latino youth. The focus of our discussion is on the implications of these findings for future development or adaptation of interventions.

Exploring the role of Natural Helpers in efforts to address disparities for children with conduct problems.

The incorporation of natural helpers into services has been suggested as an innovative strategy to address disparities for historically underserved children with conduct problems. In order to inform incorporation efforts, this study examined the perceptions of natural helpers serving one U.S. Latina/o community regarding need for services for children with conduct problems, their reactions to a specific parent training intervention, and the training and support needed to deliver this intervention successfully. Participants identified a need for culturally-responsive services for children with conduct problems, and felt that parent training would be appropriate for the families they serve. Participants further identified specific training and support that they would require in order to deliver parent training with fidelity and effectiveness. Findings support the suggestion that natural helpers have the potential to address service disparities among Latina/o children with conduct problems. Recommendations from natural helpers should guide the development of culturally-adapted preventive interventions that help address existing service disparities.