Randomized Feasibility Pilot of an Executive Functioning Intervention Adapted for Children's Mental Health Settings

The critical role of executive functioning in autism as well as the co-occurring mental health challenges common among autistic youth support to the immense value of interventions targeting executive functioning for enhancing mental health services for autistic children. The goal of the present study was to conduct a randomized feasibility trial of Unstuck and On Target, an executive functioning intervention, adapted for delivery in children's community mental health setting. Mental health therapists (n = 26) enrolled with participating autistic clients (n = 32) were randomized to receive training in and deliver the adapted Unstuck intervention or to deliver care as usual. We completed masked observational measures of Unstuck strategy use (fidelity) during recorded sessions of participating therapist-client dyads and collected measures of acceptability from participating clients and their caregivers. We also collected measures of pre-post changes in executive functioning and mental health symptoms. Therapists trained in Unstuck demonstrated significantly higher use of Unstuck strategies compared to usual care therapists. Caregivers and autistic clients perceive adapted Unstuck as highly acceptability and helpful. Autistic clients whose therapists were trained in adapted Unstuck demonstrated larger pre-post changes in executive functioning compared to usual care. Across all participating clients, changes in executive functioning were significantly related to changes in mental health symptoms. Finally, clients of therapists trained in adapted Unstuck demonstrated moderate improvements in overall mental health symptoms. The current study provides preliminary evidence of the feasibility and impact of Unstuck and On Target for children's community mental health settings.

The latent structure of the Delis-Kaplan system for autism

A core feature of autism is deficits in executive functioning (EF), including difficulty with planning, cognitive flexibility, and working memory. Despite a growing need for evidence-based assessments of EF for autism populations, statistical models of many commonly used measures of EF, including the Delis-Kaplan Executive Function System (D-KEFS), have not been investigated for a sample of autistic participants. The purpose of this study was to address a gap in the literature regarding the latent structure of the D-KEFS in a sample of autistic individuals. The D-KEFS is one of the most widely used clinical assessments of executive function, but its factor structure has not been examined in a sample of autistic participants. Reliability analyses were performed for sample subgroups based on participants' clinical and demographic characteristics, including IQ, autism severity, age, and race/ethnicity. Verbal Fluency (VF) was found to consistently decrease or not affect the overall reliability score. Additionally, one- and two-factor structure models were tested for the D-KEFS with a sample of autistic participants. The one-factor model was not found to be a good fit for the data. However, the two-factor model, with Cognitive Flexibility and Abstraction latent factors, was found to fit the data relatively well. This two-factor model was reexamined excluding the VF observed variable, resulting in a better overall model fit. Communication deficits are a common feature of autism, which explains why the VF task, that requires participants to produce novel words, may not be an adequate measure of executive function for autism populations.

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Mental health symptoms of youth initiating psychiatric care at different phases of the COVID-19 pandemic

OBJECTIVE

To examine differences in caregiver and youth reported mental health symptoms for youth initiating mental health treatment through phases of the Coronavirus Disease (COVID-19) pandemic, compared with symptomology reported the prior year.

STUDY DESIGN

This retrospective study analyzes group differences in mental health symptoms (Pediatric Symptom Checklist; PSC-35) based on 7874 youth seeking treatment in publicly funded mental health treatment programs during California's Stay-At-Home order (March-May, 2020) and the prolonged pandemic (May-December, 2020) phases of the COVID-19 pandemic as compared with matching groups in 2019.

RESULTS

Youth entering mental health treatment services, and their caregivers, reported significantly increased internalizing, externalizing, and attention-related symptoms during the prolonged pandemic phase, but not during the acute stay-at-home phase of the COVID-19 pandemic, and with small effect sizes. Group comparison analyses did not detect a significantly larger effect for Sexual and Gender Diverse (SGD) youth who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex, and Black, Indigenous, People of Color (BIPOC).

CONCLUSIONS

A large-scale comparison of youth mental health symptoms before and during the COVID-19 pandemic suggests that mental health was disrupted for youth seeking treatment as the pandemic prolonged throughout 2020.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

Purpose

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

Methods

A comparative multiple case study design was used to characterize transition practices within the literature examining children’s, non-VA adult, and VA adult service contexts. Andersen’s (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

Results

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

Conclusions

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Applying Implementation Mapping to Expand a Care Coordination Program at a Federally Qualified Health Center

Background

A large and growing percentage of medically underserved groups receive care at federally qualified health centers (FQHCs). Care coordination is an evidence-based approach to address disparities in healthcare services. A partnered FQHC established a care coordination model to improve receipt and quality of healthcare for patients most at risk for poor health outcomes. This care coordination model emphasizes identification and support of behavioral health needs (e.g., depression, anxiety) and two evidence-based behavioral health programs needs were selected for implementation within the context of this care coordination model. Implementation Mapping is a systematic process for specifying the implementation strategies and outcomes. The current case study describes the application of Implementation Mapping to inform the selection and testing of implementation strategies to improve implementation of two behavioral health programs in a Care Coordination Program at a partnered FQHC.

Methods

We applied Implementation Mapping to inform the development, selection and testing of implementation strategies to improve the implementation of two evidence-based behavioral health programs within a care coordination program at a partnered FQHC.

Results

Results are presented by Implementation Mapping task, from Task 1 through Task 5. We also describe the integration of additional implementation frameworks (The Consolidated Framework for Implementation Research, Health Equity Implementation Framework) within the Implementation Mapping process to inform determinant identification, performance and change objectives development, design and tailoring of implementation strategies and protocols, and resulting evaluation of implementation outcomes.

Conclusions

The current project is an example of real-world application of Implementation Mapping methodology to improve care outcomes for a high priority population that is generalizable to other settings utilizing similar care models and health equity endeavors. Such case studies are critical to advance our understanding and application of innovative implementation science methods such as Implementation Mapping.

Mental Health Therapist Perspectives on the Role of Executive Functioning in Children's Mental Health Services

Executive functioning is considered a key transdiagnostic factor underlying multiple mental health conditions. Evidence-based interventions targeting executive functioning skills exist and there are ongoing efforts to implement these interventions in routine community-based care. However, there is limited research characterizing therapist perspectives regarding addressing executive functioning within community-based mental health services. The current mixed-methods study aims to characterize mental health therapist perspectives regarding the role of executive functioning in youth clinical presentation and the psychotherapy process and outcomes as well as their experience and training related to executive functioning. Forty-three therapists completed a survey about their perspectives about executive functioning and 14 participated in subsequent focus groups to expand survey results. Results indicated that therapists perceive executive functioning challenges as impacting a large portion of children on their caseload, present across multiple mental health conditions, and that executive functioning is frequently a focus of psychotherapy. Therapists also identified executive functioning challenges as a barrier to therapy engagement and effectiveness. However, therapists reported limited knowledge and training as well as significant motivation for executive functioning training, including executive functioning interventions. Findings confirm the significant role of executive functioning in youth presenting for mental health services and the psychotherapy process and outcomes. Findings also highlight the need for further translation of evidence-based interventions and tools. Challenges as well as potential solutions to inform ongoing and future work seeking to translate and implement evidence-based executive functioning interventions in community mental health services are discussed.

Provider perspectives and reach of an evidence-based intervention in community services for toddlers

Best-practice recommendations for young children at high likelihood of autism include active involvement of caregivers in intervention. However, the use of evidence-based parent-mediated interventions in community practice remains limited. Preliminary evidence suggests that Project ImPACT for Toddlers demonstrates positive parent and child outcomes in community settings. Project ImPACT for Toddlers was adapted specifically for toddlers and teaches parents of young children strategies to build their child’s social, communication, and play skills in daily routines. This study reports implementation outcomes from the initial community rollout of Project ImPACT for Toddlers and examines the system-wide intervention reach, with the goal of informing continued community sustainment and scale-up. Participants include 38 community providers who participated in a Project ImPACT for Toddlers’ training study who completed an implementation survey and semi-structured interviews after approximately 3 months of community implementation. Participants perceived the training model as acceptable and appropriate, and identified several strengths of the approach. Interview themes also supported the feasibility, acceptability, and utility of the intervention in community settings. Quantitative findings complemented the thematic results from interviews. Intervention reach data indicate an increasing number of agencies delivering and families receiving Project ImPACT for Toddlers. Efforts to scale-up evidence-based interventions in early intervention should continue to build upon the model of the Bond, Regulate, Interact, Develop, Guide, and Engage Collaborative.

Lay abstract

Expert recommendations for toddlers who are likely to develop autism include caregivers being actively involved in the services children receive. However, many services available in the community may not follow these recommendations. Evidence suggests that an intervention named Project ImPACT for Toddlers demonstrates positive parent and child outcomes for families in the community. Project ImPACT for Toddlers was designed specifically for toddlers by a group of parents, clinicians, researchers, and funders. It teaches parents of young children strategies to support their child’s development in daily routines. This study reports the perspectives of early intervention providers who learned to use Project ImPACT for Toddlers on whether the intervention was a good fit for their practice and easy to use. The study also examines how many agencies are using Project ImPACT for Toddlers and how many families have received the intervention in the community. The goal of the study is to inform the continued use of Project ImPACT for Toddlers in the community and support offering the intervention in other regions. Participants include 38 community providers who participated in a training study of Project ImPACT for Toddlers and completed a survey and semi-structured interview after approximately 3 months of using Project ImPACT for Toddlers with families. Participants perceived the training model as acceptable and appropriate, and identified the group-based model of training, comprehensive materials, and agency support as strengths of the approach. Survey findings complemented the results from the interviews. Data indicate an increasing number of agencies and families accessing Project ImPACT for Toddlers. Efforts to expand evidence-based intervention in early intervention should continue to build upon the model used for Project ImPACT for Toddlers.

Short report: A quantitative methodological review of participant characteristics in the literature testing mental health interventions for youth with autism spectrum disorder

LAY ABSTRACT

Previous research has highlighted the importance of mental health treatment for autistic youth. In that research base, most studies focus on demonstrating the efficacy of a particular intervention with a sample of autistic youth. However, understanding the characteristics of samples used within these studies (i.e. demographics) is an important avenue for expanding this research to a more diverse, representative sample of autistic youth in community settings. As such, the current review examined and characterized participants included within mental health treatment research. We coded studies for various demographics among the youth sample, caregivers, and providers participants. Results indicated that while efforts have been made to increase diversity in research, very few studies including transition-aged youth, those identifying as female, and/or those identifying as non-Caucasian. Clinically, a few studies included youth with lower cognitive abilities and/or those with specific mental health problems (e.g. trauma and depression) or more than one co-occurring mental health conditions. Overall, our results highlight several critical gaps in our current evidence base regarding mental health treatment for autistic youth, including the limited clinical representativeness of both provider and child participants.

A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps

PURPOSE OF REVIEW

This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population.

RECENT FINDINGS

Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

Correction to: A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Due to the errors occurred in the originally published version, this article is being reprinted in its entirety as Correction. All errors have been corrected. It is the correct version.

Forms and functions of bridging factors: specifying the dynamic links between outer and inner contexts during implementation and sustainment

BACKGROUND

Bridging factors are relational ties, formal arrangements, and processes that connect outer system and inner organizational contexts. They may be critical drivers of evidence-based practice (EBP) implementation and sustainment. Yet, the complex interplay between outer and inner contexts is often not considered. Bridging factors were recently defined in the updated Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Further identification and specification of this construct will advance implementation models, measures, and methods. Our goal is to advance bridging factor research by identifying relevant dimensions and exemplifying these dimensions through illustrative case studies.

METHODS

We used a multiple case study design. Each case (n = 10) represented different contexts, EBPs, and bridging factor types. Inclusion criteria were the presence of clearly distinguishable outer and inner contexts, identifiable bridging factor, sufficient information to describe how the bridging factor affected implementation, and variation from other cases. We used an iterative qualitative inquiry process to develop and refine a list of dimensions. Case data were entered into a matrix. Dimensions comprised the rows and case details comprised the columns. After a review of all cases, we collectively considered and independently coded each dimension as function or form.

RESULTS

We drew upon the concepts of functions and forms, a distinction originally proposed in the complex health intervention literature. Function dimensions help define the bridging factor and illustrate its purpose as it relates to EBP implementation. Form dimensions describe the specific structures and activities that illustrate why and how the bridging factor has been customized to a local implementation experience. Function dimensions can help researchers and practitioners identify the presence and purpose of bridging factors, whereas form dimensions can help us understand how the bridging factor may be designed or modified to support EBP implementation in a specific context. We propose five function and three form bridging factor dimensions.

CONCLUSIONS

Bridging factors are described in many implementation models and studies, but without explicit reference or investigation. Bridging factors are an understudied and critical construct that requires further attention to facilitate implementation research and practice. We present specific recommendations for a bridging factors research agenda.

Concordance between Community Supervisor and Provider Ratings of Fidelity: Examination of Multi-Level Predictors and Outcomes

Fidelity is conceptualized as a key mechanism impacting treatment outcomes, yet community examination of fidelity is limited, partly due to limited feasible training methods and tools. Provider-report tools represent a feasible method for improving routine fidelity monitoring. Additional work examining the effectiveness of these methods and concordance with other fidelity sources is needed. Further, provider and client factors impact both intervention implementation and concordance, but their impact on fidelity measurement is poorly understood. Using a train-the-trainer methodology, we examine concordance between three methods of assessing fidelity (trained independent coders, supervisor evaluation and provider self-report) using a fidelity assessment tool adapted for community use. Multilevel models examined predictors (provider- and child- level factors) and outcomes (provider average fidelity) of concordance. Results suggest supervisors and providers are able to use the fidelity tool, but demonstrated variable concordance, with higher concordance with trained coders for supervisors than providers. Provider credentials and child language were marginally predictive of rater concordance. Higher supervisor accuracy was associated with higher provider fidelity. Findings inform broader efforts to improve the development and implementation of feasible fidelity tools for routine use in community settings and highlight multi-level factors impacting the adoption and implementation of such tools.

Advancing the pragmatic measurement of sustainment: a narrative review of measures

BACKGROUND

Sustainment, an outcome indicating an intervention continues to be implemented over time, has been comparatively less studied than other phases of the implementation process. This may be because of methodological difficulties, funding cycles, and minimal attention to theories and measurement of sustainment. This review synthesizes the literature on sustainment measures, evaluates the qualities of each measure, and highlights the strengths and gaps in existing sustainment measures. Results of the review will inform recommendations for the development of a pragmatic, valid, and reliable measure of sustainment.

METHODS

A narrative review of published sustainment outcome and sustainability measures (i.e., factors that influence sustainment) was conducted, including appraising measures in the Society of Implementation Research Collaboration (SIRC) instrument review project (IRP) and the Dissemination and Implementation Grid-Enabled Measures database initiative (GEM-D&I). The narrative review used a snowballing strategy by searching the reference sections of literature reviews and definitions of sustainability and sustainment. Measures used frequently and judged to be comprehensive and/or validated by a team of implementation scientists were extracted for analysis.

RESULTS

Eleven measures were evaluated. Three of the included measures were found in the SIRC-IRP, three in the GEM-D&I database, (one measure was in both databases) and six were identified in our additional searches. Thirteen constructs relating to sustainment were coded from selected measures. Measures covered a range of determinants for sustainment (i.e., construct of sustainability) as well as constructs of sustainment as an outcome. Strengths of the measures included, development by expert panels knowledgeable about particular interventions, fields or contexts, and utility in specific scenarios. A number of limitations were found in the measures analyzed including inadequate assessment of psychometric characteristics, being overly intervention or context specific, being lengthy and/or complex, and focusing on outer context factors.

CONCLUSION

There is a lack of pragmatic and psychometrically sound measures of sustainment that can be completed by implementation stakeholders within inner context settings (e.g., frontline providers, supervisors).

Ten recommendations for using implementation frameworks in research and practice

Background

Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

Discussion

Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Summary

The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

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

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

Impact of Therapist Training on Parent Attendance in Mental Health Services for Children with ASD

OBJECTIVE

The current study explored the impact of training therapists in a mental health intervention for children with autism spectrum disorder (ASD) on parent attendance in their children's therapy sessions. We also examined family, therapist, and program factors as potential moderators.

METHOD

Data were drawn from a cluster-randomized community effectiveness trial of "An Individualized Mental Health Intervention for ASD (AIM HI)". Participants included 168 therapists yoked with 189 children recruited from publicly-funded mental health services. Data included family (caregiver strain, parent sense of competence, race/ethnicity), therapist (background, experience), and program (service setting) characteristics, and parent session attendance. Multilevel models were used to evaluate the effectiveness of AIM HI therapist training on caregiver attendance and identify moderators of training effects on parent attendance.

RESULTS

Parents attended a higher percentage of sessions in the AIM HI training condition compared to the Usual Care condition. Program service setting moderated the effect of AIM HI training, with higher parent attendance in non-school (mostly outpatient) settings compared to school settings and a significantly smaller difference between the settings in the AIM HI condition.

CONCLUSIONS

Effective strategies to promote parent engagement, especially in service settings such as schools, are warranted. Findings support the effectiveness of AIM HI training in promoting parent attendance across multiple publicly-funded mental health service settings. The larger effect in school-based programs supports the utility of training in evidence-based interventions such as AIM HI to increase the feasibility of parent attendance in such services.

Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services

Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.

Adapting parent engagement strategies for an evidence-based parent-mediated intervention for young children at risk for autism spectrum disorder

AIMS

Aims included (a) characterizing provider feedback on parent engagement strategies integrated into a parent-mediated intervention for toddlers at risk for autism spectrum disorder (ASD) and (b) identifying provider characteristics that predict attitudes about parent engagement strategies.

METHODS

A mixed method approach was utilized, including gathering quantitative data via survey (breadth) and collecting qualitative data via interview (depth). Acceptability, utility, appropriateness, sustainment, generalizability, and perceived effectiveness were examined. Fourteen agency leaders and 24 therapists provided input.

RESULTS

Providers perceived the integration of parent engagement strategies as having a positive impact on implementation. Providers considered the strategies to be acceptable, appropriate, and effective, though barriers of time and complexity were noted. Provider characteristics did not consistently predict attitudes about the engagement strategies.

CONCLUSIONS

Incorporating parent engagement strategies into parent-mediated interventions for ASD is well-received by providers and may improve quality of service delivery for families served in early intervention for ASD.

Ten recommendations for using implementation frameworks in research and practice

Background

Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

Discussion

Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Summary

The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

Adaption and pilot implementation of an autism executive functioning intervention in children's mental health services: a mixed-methods study protocol

BACKGROUND

Youth with autism spectrum disorder (ASD) represent a growing population with significant service needs. Prominent among these needs are high rates of co-occurring psychiatric conditions that contribute to increased functional impairments and often necessitate mental health services. Executive functioning deficits are associated with ASD as well as common co-occurring conditions (e.g., attention-deficit/hyperactivity disorder) and an evidence-based intervention has been developed and tested to address executive functioning within the school context. There is an urgent need to implement indicated evidence-based interventions for youth with ASD receiving care in community mental health settings. Interventions that optimally "fit" the mental health services context as well as the complex and co-occurring mental health needs of these youth have the potential to improve key clinical outcomes for this high priority population.

METHODS

This mixed-methods developmental study will apply the Exploration, Preparation, Implementation, Sustainment implementation framework and a community-academic partnership approach to systematically adapt and test an evidence-based executive functioning intervention for youth with ASD for delivery in community mental health settings. Specific aims are to (1) conduct a need and context assessment to inform the systematic adaptation an executive functioning evidence-based intervention; (2) systematically adapt the clinical intervention and develop a corresponding implementation plan, together entitled "Executive Functioning for Enhancing Community-based Treatment for ASD," (EFFECT for ASD); and (3) conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.

DISCUSSION

Tailoring evidence-based interventions for delivery in community-based mental health services for youth with ASD has the potential to increase quality of care and improve child outcomes. Results from the current study will serve as the foundation for large-scale hybrid implementation and effectiveness trials and a generalizable approach for different service systems of care and clinical populations.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04295512.

Project ImPACT for Toddlers: Pilot outcomes of a community adaptation of an intervention for autism risk

This study reports child and family outcomes from a community-based, quasi-experimental pilot trial of Project ImPACT for Toddlers that is a parent-mediated, naturalistic, developmental behavioral intervention for children with or at-risk for autism spectrum disorder developed through a research-community partnership. Community early interventionists delivered either Project ImPACT for Toddlers (n = 10) or Usual Care (n = 9) to families based on Part C assigned provider. Twenty-five families participated, with children averaging 22.76 months old (SD = 5.06). Family and child measures were collected at intake, after 3 months of service, and after a 3-month follow-up. Results indicate significantly greater improvements in positive parent-child interactions for Project ImPACT for Toddlers than usual care families, as well as large, but non-significant, effect sizes for Project ImPACT for Toddlers families in children's social and communication skills.

Parent Mental Health Problems and Motivation as Predictors of Their Engagement in Community-Based Child Mental Health Services

Parent or caregiver engagement in child mental health treatment is an important element of treatment effectiveness, particularly for children with disruptive behavior problems. Parent or caregiver characteristics, such as their mental health and/or motivation to participate in treatment, may impact engagement and subsequent treatment outcomes. However, a lack of empirical research exists examining these potential links, particularly in community-based treatment settings. The current pilot study: 1) examines whether parent mental health problems and/or early parent motivation to participate in treatment predict three indicators of parent engagement in child treatment, controlling for the other predictor; and 2) examines and compares the differential influence of parent mental health and parent motivation on each parent engagement indicator. Participants in this study include 19 dyads from 18 therapists who were recruited from community mental health clinics. Results indicated a significant association between parent mental health and session attendance, and a marginally significant association between parent mental health and therapist-rated parent engagement. Parent mental health predicted outcomes above and beyond parent motivation. These findings preliminarily suggest that parent mental health problems early in child mental health treatment may be important to consider as an impactful target to promote parent treatment engagement, in addition to focusing on parent motivation to participate in treatment.

Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods

A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1–5 scale).

Results

In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5).

Conclusion

This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0842-6) contains supplementary material, which is available to authorized users.

Parent and Teacher Concordance of Child Outcomes for Youth with Autism Spectrum Disorder

Cross-informant ratings of are considered gold standard for child behavioral assessment. To date, little work has examined informant ratings of adaptive functioning for youth with autism spectrum disorder (ASD). In a large, diverse sample of youth with ASD, this study evaluated parent-teacher concordance of ratings of adaptive functioning and ASD-specific symptomatology across time. The impact of child clinical characteristics on concordance was also examined. Participants included 246 children, their caregivers and teachers. Parent-teacher concordance was variable but generally consistent across time. Concordance was significantly impacted by autism severity and child cognitive abilities. Findings inform the broader concordance literature and support the need to consider child clinical factors when assessing child functioning in samples of children with ASD.

Integrating a Parent-Implemented Blend of Developmental and Behavioral Intervention Strategies into Speech-Language Treatment for Toddlers at Risk for Autism Spectrum Disorder

Naturalistic developmental behavioral interventions include an explicit focus on coaching parents to use therapy techniques in daily routines and are considered best practice for young children with autism. Unfortunately, these approaches are not widely used in community settings, possibly due to the clinical expertise and training required. This article presents the work of the Bond, Regulate, Interact, Develop, Guide, Engage (BRIDGE Collaborative), a multidisciplinary group of service providers (including speech-language pathologists), parents, funding agency representatives, and researchers dedicated to improving the lives of young children with autism spectrum disorder and their families. The group selected and adapted a parent coaching naturalistic developmental behavioral intervention specifically for use with toddlers and their families for community implementation. Lessons learned from the implementation process include the importance of therapist background knowledge, the complexity of working with parents of young children, and needed supports for those working closely with parents, including specific engagement strategies and the incorporation of reflective practice.

Examining ethnic disparities in provider and parent in-session participation engagement

PURPOSE

Well-documented ethnic disparities exist in the identification and provision of quality services among children receiving community-based mental health services. These disparities extend to parent treatment engagement, an important component of effective mental health services. Currently, little is known about differences in how providers support parents' participation in treatment and the degree to which parents actively participate in it. The purpose of this paper is to examine potential differences in both provider and parent in-session participation behaviours.

DESIGN/METHODOLOGY/APPROACH

Participants included 17 providers providing standard community-based mental health treatment for 18 parent-child dyads, with 44 per cent of the dyads self-identifying as Hispanic/Latino. In-session participation was measured with the parent participation engagement in child psychotherapy and therapist alliance, collaboration, and empowerment strategies observational coding systems.

FINDINGS

Overall, results indicate significantly lower levels of parent participation behaviours among Hispanic/Latino families compared to their Non-Hispanic/Non-Latino counterparts. No significant differences were seen in providers' in-session behaviours to support parent participation across Hispanic/Latino and Non-Hispanic/Non-Latino families.

RESEARCH LIMITATIONS/IMPLICATIONS

These findings contribute to the literature on ethnic differences in parent treatment engagement by utilising measures of in-session provider and parent behaviours and suggest that further investigation is warranted to documenting and understanding ethnic disparities in parents' participation in community-based child mental health treatment.

ORIGINALITY/VALUE

This paper contributes to the evaluation of differences in parent treatment engagement through demonstrating the utility of an in-session observational coding system as a measure of treatment engagement.

Adolescents' co-rumination and stress predict affective changes in a daily-diary paradigm

Co-rumination has been related to both high quality friendship and depressive symptoms. However, little is known regarding the extent to which co-rumination may be detrimental, its distinction from rumination and potential gender differences in co-rumination. This study used a modified version of Rose's Co-rumination Questionnaire (Rose, 2002) to examine the behaviour of daily co-rumination with daily stress and negative affect among adolescents. Results demonstrated that co-rumination did not have a main effect in predicting negative affect, but did evidence a significant interaction with life stress. Additionally, co-rumination demonstrated incremental utility above that of rumination. Finally, gender differences were not supported. In conclusion, this investigation revealed that co-rumination exacerbates the effects of life stress and is predictive of increased internalising symptoms.

Rumination, worry, cognitive avoidance, and behavioral avoidance: examination of temporal effects

Recently, cross-sectional research has demonstrated that depressive rumination is significantly associated with the tendency to engage in cognitive and behavioral avoidance. This evidence suggests that rumination may be the result of attempts to avoid personally threatening thoughts, in a manner suggested by multiple contemporary theories of worry. This investigation examined the temporal relationship among daily levels of cognitive avoidance, behavioral avoidance, rumination, worry, and negative affect. Seventy-eight adolescents completed baseline questionnaires and then electronically completed daily measures of rumination, worry, behavioral avoidance, and cognitive avoidance, as well as sad and anxious affect for 7 days. Lagged-effect multilevel models indicated that increases in daily sadness were predicted by greater daily rumination and cognitive avoidance. Increases in daily anxiety were predicted by greater daily rumination, worry, and both cognitive and behavioral avoidance. Further, both daily rumination and worry were positively predicted by daily cognitive, but not behavioral, avoidance. Mediation analyses suggested that rumination mediated the effect of cognitive avoidance on both sadness and anxiety. Also, worry mediated the effect of cognitive avoidance on anxiety. Implications for models of avoidance, rumination, and worry are discussed.

Dispositional mindfulness moderates the effects of stress among adolescents: rumination as a mediator

Recent research has demonstrated that higher levels of mindfulness are associated with greater psychological and physical health. However, the majority of this research has been conducted with adults; research is only beginning to examine the effects of mindfulness among adolescents. Further, research into adolescent mindfulness has typically conceptualized mindfulness as a unidimensional phenomenon and has not yet examined multidimensional models of mindfulness that have emerged in the adult literature. Further, the mechanisms through which mindfulness influences these outcomes are presently unclear. The present study examined the effects of three facets of mindfulness among adolescents. Seventy-eight adolescents (61% female, 94% Caucasian, M age = 16) completed a measure of dispositional mindfulness at baseline. Participants then completed measures of daily stress, dysphoric affect, and state rumination over a 7-day period. Multilevel modeling analyses revealed that facets of mindfulness (i.e., nonreactivity and nonjudgment) were associated with lower levels of dysphoric mood. Mindfulness interacted with daily stress to predict later dysphoria; less mindful individuals were particularly vulnerable to the negative effects of stress. Finally, analyses demonstrated that the effect of the Mindfulness × Stress Moderation was significantly mediated by increases in daily rumination. These findings support the importance of mindfulness among adolescents and help to elucidate the mechanisms through which mindfulness influences psychological health.

Poly(A) polymerase and the regulation of cytoplasmic polyadenylation

Translational activation in oocytes and embryos is often regulated via increases in poly(A) length. Cleavage and polyadenylation specificity factor (CPSF), cytoplasmic polyadenylation element binding protein (CPEB), and poly(A) polymerase (PAP) have each been implicated in cytoplasmic polyadenylation in Xenopus laevis oocytes. Cytoplasmic polyadenylation activity first appears in vertebrate oocytes during meiotic maturation. Data presented here shows that complexes containing both CPSF and CPEB are present in extracts of X. laevis oocytes prepared before or after meiotic maturation. Assessment of a variety of RNA sequences as polyadenylation substrates indicates that the sequence specificity of polyadenylation in egg extracts is comparable to that observed with highly purified mammalian CPSF and recombinant PAP. The two in vitro systems exhibit a sequence specificity that is similar, but not identical, to that observed in vivo, as assessed by injection of the same RNAs into the oocyte. These findings imply that CPSFs intrinsic RNA sequence preferences are sufficient to account for the specificity of cytoplasmic polyadenylation of some mRNAs. We discuss the hypothesis that CPSF is required for all polyadenylation reactions, but that the polyadenylation of some mRNAs may require additional factors such as CPEB. To test the consequences of PAP binding to mRNAs in vivo, PAP was tethered to a reporter mRNA in resting oocytes using MS2 coat protein. Tethered PAP catalyzed polyadenylation and stimulated translation approximately 40-fold; stimulation was exclusively cis-acting, but was independent of a CPE and AAUAAA. Both polyadenylation and translational stimulation required PAPs catalytic core, but did not require the putative CPSF interaction domain of PAP. These results demonstrate that premature recruitment of PAP can cause precocious polyadenylation and translational stimulation in the resting oocyte, and can be interpreted to suggest that the role of other factors is to deliver PAP to the mRNA.

Multiple portions of poly(A)-binding protein stimulate translation in vivo

Translational stimulation of mRNAs during early development is often accompanied by increases in poly(A) tail length. Poly(A)-binding protein (PAB) is an evolutionarily conserved protein that binds to the poly(A) tails of eukaryotic mRNAs. We examined PAB's role in living cells, using both Xenopus laevis oocytes and Saccharomyces cerevisiae, by tethering it to the 3'-untranslated region of reporter mRNAs. Tethered PAB stimulates translation in vivo. Neither a poly(A) tail nor PAB's poly(A)-binding activity is required. Multiple domains of PAB act redundantly in oocytes to stimulate translation: the interaction of RNA recognition motifs (RRMs) 1 and 2 with eukaryotic initiation factor-4G correlates with translational stimulation. Interaction with Paip-1 is insufficient for stimulation. RRMs 3 and 4 also stimulate, but bind neither factor. The regions of tethered PAB required in yeast to stimulate translation and stabilize mRNAs differ, implying that the two functions are distinct. Our results establish that oocytes contain the machinery necessary to support PAB-mediated translation and suggest that PAB may be an important participant in translational regulation during early development.

Determination of the free-energy change for repair of a DNA phosphodiester bond

The repair of phosphodiester bonds in nicked DNA is catalyzed by DNA ligases. Ligation is coupled to cleavage of a phosphoanhydride bond in a nucleotide cofactor resulting in a thermodynamically favorable process. A free energy value for phosphodiester bond formation was calculated using the reversibility of the T4 DNA ligase reaction. The relative number of DNA nicks to phosphodiester bonds in a circular plasmid DNA, formed during this reaction at fixed concentrations of ATP to AMP and PP(i), was quantified. At 25 degrees C, pH 7, the equilibrium constant (K(eq)) for the ligation reaction is 3.89 x 10(4) m. This value corresponds to a standard free energy (DeltaG degrees ') of -6.3 kcal mol(-1). By subtracting the known energy contribution due to hydrolysis of ATP to AMP and PP(i), DeltaG degrees ' for the hydrolysis of a DNA phosphodiester bond is -5.3 kcal mol(-1).

Translational control of cyclin B1 mRNA during meiotic maturation: coordinated repression and cytoplasmic polyadenylation

Translational control is prominent during meiotic maturation and early development. In this report, we investigate a mode of translational repression in Xenopus laevis oocytes, focusing on the mRNA encoding cyclin B1. Translation of cyclin B1 mRNA is relatively inactive in the oocyte and increases dramatically during meiotic maturation. We show, by injection of synthetic mRNAs, that the cis-acting sequences responsible for repression of cyclin B1 mRNA reside within its 3'UTR. Repression can be saturated by increasing the concentration of reporter mRNA injected, suggesting that the cyclin B1 3'UTR sequences provide a binding site for a trans-acting repressor. The sequences that direct repression overlap and include cytoplasmic polyadenylation elements (CPEs), sequences known to promote cytoplasmic polyadenylation. However, the presence of a CPE per se appears insufficient to cause repression, as other mRNAs that contain CPEs are not translationally repressed. We demonstrate that relief of repression and cytoplasmic polyadenylation are intimately linked. Repressing elements do not override the stimulatory effect of a long poly(A) tail, and polyadenylation of cyclin B1 mRNA is required for its translational recruitment. Our results suggest that translational recruitment of endogenous cyclin B1 mRNA is a collaborative effect of derepression and poly(A) addition. We discuss several molecular mechanisms that might underlie this collaboration.

The cleavage and polyadenylation specificity factor in Xenopus laevis oocytes is a cytoplasmic factor involved in regulated polyadenylation

During early development, specific mRNAs receive poly(A) in the cytoplasm. This cytoplasmic polyadenylation reaction correlates with, and in some cases causes, translational stimulation. Previously, it was suggested that a factor similar to the multisubunit nuclear cleavage and polyadenylation specificity factor (CPSF) played a role in cytoplasmic polyadenylation. A cDNA encoding a cytoplasmic form of the 100-kDa subunit of Xenopus laevis CPSF has now been isolated. The protein product is 91% identical at the amino acid sequence level to nuclear CPSF isolated from Bos taurus thymus. This report provides three lines of evidence that implicate the X. laevis homologue of the 100-kDa subunit of CPSF in the cytoplasmic polyadenylation reaction. First, the protein is predominantly localized to the cytoplasm of X. laevis oocytes. Second, the 100-kDa subunit of X. laevis CPSF forms a specific complex with RNAs that contain both a cytoplasmic polyadenylation element (CPE) and the polyadenylation element AAUAAA. Third, immunodepletion of the 100-kDa subunit of X. laevis CPSF reduces CPE-specific polyadenylation in vitro. Further support for a cytoplasmic form of CPSF comes from evidence that a putative homologue of the 30-kDa subunit of nuclear CPSF is also localized to the cytoplasm of X. laevis oocytes. Overexpression of influenza virus NS1 protein, which inhibits nuclear polyadenylation through an interaction with the 30-kDa subunit of nuclear CPSF, prevents cytoplasmic polyadenylation, suggesting that the cytoplasmic X. laevis form of the 30-kDa subunit of CPSF is involved in this reaction. Together, these results indicate that a distinct, cytoplasmic form of CPSF is an integral component of the cytoplasmic polyadenylation machinery.