Statewide Implementation of Parenting with Love and Limits Among Youth with Co-Existing Internalizing and Externalizing Functional Impairments Reduces Return to Service Rates and Treatment Costs

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

BACKGROUND

Child and Adolescent Mental Health Services (CAMHS) in England are making significant changes to improve access and effectiveness. This 'transformation' variously involves easier access to services through a Single Point of Access (SPA), more integrated services within CAMHS and enhanced co-provision across education and third sector or non-profit organisations.

METHODS

A mixed-methods observational study was conducted to explore the process and impact of transformation over four years in two services. Ethnographic observations and in-depth interviews were conducted and Electronic Patient Records with over one million contacts analysed. Difference-in-differences analysis with propensity score matching to estimate the causal impact of the transformation on patient access was utilised.

OUTCOMES

Spend and staffing increased across both CAMHS. The SPA had growing rates of self-referral and new care pathways were seeing patients according to expected degree of psychopathology. Third sector partners were providing increasing numbers of low-intensity interventions. Although the majority of staff were supportive of the changes, the process of transformation led to service tensions. In the first year after transformation there was no change in the rate of new patients accessing services or new spells (episodes of care) in the services. However, by year three, the number of new patients accessing CAMHS was 19% higher (Incidence Rate Ratio: 1·19, CI: 1·16, 1·21) and the rate of new spells was 12% higher (Incidence Rate Ratio: 1·12, CI: 1·05, 1·20).

INTERPRETATION

Transformation investment, both financial and intellectual, can help to increase access to CAMHS in England, but time is needed to realise the benefits of reorganisation.

An Exploratory Study of a Training Team-Coordinated Approach to Implementation

Background

It is now widely understood that successful implementation of evidence-based treatments is facilitated by several favorable conditions (e.g., community buy-in, invested agency leadership). However, strategies for supporting agencies in promoting these conditions have been examined to a lesser extent. In this exploratory study, the implementation support procedures of Parenting with Love and Limits (PLL), an evidence-informed family treatment for child/adolescent behavior problems in which the training team follows structured procedures to help coordinate implementation support activities, are illustrated, and their preliminary effectiveness examined.

Methods

PLL documents and communication records between PLL and n = 23 sites across the U.S. that initiated PLL pre-implementation activities were reviewed. In addition, implementation activities completed for each agency were entered into the Stages of Implementation Completion (SIC) dashboard.

Results

The prescriptive nature of the PLL implementation support protocol was illustrated through descriptions of procedural documents and case examples. Quantitative analyses revealed that, among the 23 sites that began pre-implementation, 9 discontinued, with a trend toward sites in metropolitan areas being more likely to discontinue than those in less populous areas. In addition, the 14 sites that launched PLL demonstrated a high amount of consistency in activities, with sites in the sustainability phase completing an average of 86% of implementation behaviors.

Conclusions

Training team-coordination of implementation activities may be one promising approach for supporting agencies in completing tasks to facilitate successful uptake of evidence-supported interventions. In turn, sustained implementation of evidence-supported treatments could allow communities to benefit from practice innovations to a greater extent.

Measures of Facilitator Competent Adherence Used in Parenting Programs and Their Psychometric Properties: A Systematic Review

Implementation fidelity is a critical component of intervention science, which aims to understand how interventions unfold in practice to improve outcomes. A key element of fidelity is facilitator competent adherence-the extent to which a program is delivered as prescribed with the specified level of quality. We conducted a two-part systematic review examining these aspects in parenting programs aiming to reduce child behavior problems and maltreatment. Part One reviews measures of facilitator competent adherence and Part Two examines the psychometric properties of the observational measures found. Searches identified 9153 articles from electronic databases, citation tracking, and expert input. After screening using pre-specified criteria, 156 (Part One) and 41 (Part Two) articles remained. In Part One, measure, facilitator, and intervention characteristics were extracted and synthesized from 65 measures. Most measures were observational, used by facilitators and researchers, and employed Likert-scale ratings. In Part Two, evidence on the reliability (internal consistency, inter-rater, intra-rater, test-retest) and validity (content, construct, convergent/divergent, criterion) of 30 observational measures identified from Part One was synthesized and evaluated. An adapted COSMIN checklist was used to assess study and measure quality. We found most studies to be of reasonably high quality. This is the first review to summarize and critically appraise measures of facilitator competent adherence used in the parenting program literature and establish their psychometric properties. The findings underscore the need to advance research on measures of facilitator competent adherence; reliable, valid, and high-quality implementation measures allow for evidence-based decisions regarding the delivery and scale-up of parenting programs. PROSPERO Registration Number: CRD42020167872.