Amy E. Green

Dissemination and Implementation of Evidence-Based Practices for Child and Adolescent Mental Health: A Systematic Review

OBJECTIVE Although there has been a dramatic increase in the number of evidence-based practices (EBPs) to improve child and adolescent mental health, the poor uptake of these EBPs has led to investigations of factors related to their successful dissemination and implementation. The purpose of this systematic review was to identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health. METHOD Of 14,247 citations initially identified, 73 articles drawn from 44 studies met inclusion criteria. The articles were classified by implementation phase (exploration, preparation, implementation, and sustainment) and specific implementation factors examined. These factors were divided into outer (i.e., system level) and inner (i.e., organizational level) contexts. RESULTS Few studies used true experimental designs; most were observational. Of the many inner context factors that were examined in these studies (e.g., provider characteristics, organizational resources, leadership), fidelity monitoring and supervision had the strongest empirical evidence. Albeit the focus of fewer studies, implementation interventions focused on improving organizational climate and culture were associated with better intervention sustainment as well as child and adolescent outcomes. Outer contextual factors such as training and use of specific technologies to support intervention use were also important in facilitating the implementation process. CONCLUSIONS The further development and testing of dissemination and implementation strategies is needed to more efficiently move EBPs into usual care.

Dynamic adaptation process to implement an evidence-based child maltreatment intervention

BackgroundAdaptations are often made to evidence-based practices (EBPs) by systems, organizations, and/or service providers in the implementation process. The degree to which core elements of an EBP can be maintained while allowing for local adaptation is unclear. In addition, adaptations may also be needed at the system, policy, or organizational levels to facilitate EBP implementation and sustainment. This paper describes a study of the feasibility and acceptability of an implementation approach, the Dynamic Adaptation Process (DAP), designed to allow for EBP adaptation and system and organizational adaptations in a planned and considered, rather than ad hoc, way. The DAP involves identifying core elements and adaptable characteristics of an EBP, then supporting implementation with specific training on allowable adaptations to the model, fidelity monitoring and support, and identifying the need for and solutions to system and organizational adaptations. In addition, this study addresses a secondary concern, that of improving EBP model fidelity assessment and feedback in real-world settings.MethodsThis project examines the feasibility, acceptability, and utility of the DAP; tests the degree to which fidelity can be maintained using the DAP compared to implementation as usual (IAU); and examines the feasibility of using automated phone or internet-enabled, computer-based technology to assess intervention fidelity and client satisfaction. The study design incorporates mixed methods in order to describe processes and factors associated with variations in both how the DAP itself is implemented and how the DAP impacts fidelity, drift, and adaptation. The DAP model is to be examined by assigning six regions in California (USA) to either the DAP (n = 3) or IAU (n = 3) to implement an EBP to prevent child neglect.DiscussionThe DAP represents a data-informed, collaborative, multiple stakeholder approach to maintain intervention fidelity during the implementation of EBPs in the field by providing support for intervention, system, and organizational adaptation and intervention fidelity to meet local needs. This study is designed to address the real-world implications of EBP implementation in public sector service systems and is relevant for national, state, and local service systems and organizations.

Multiple informants in the assessment of psychological, behavioral, and academic correlates of bullying and victimization in middle school

The present study assessed agreement between student self-report and teacher ratings of bullying and victimization relative to psychological, behavioral, and academic correlates. Middle school students (N=1442) and teachers completed surveys evaluating peer relationships and psychosocial adjustment. Analyses of variance and logistic regressions were used to examine rater agreement on bullying/victimization and adjustment among groups (bullies, victims, bully/victims, and uninvolved) identified by rater (student self-report only, teacher-report only, concordant reports, and controversial reports). Concordant and controversial groups had among the greatest psychosocial and academic difficulties. Student learning difficulties and moodiness interacted with teacher reports of bullying and victimization, respectively, with agreement between teacher and student self reports of bullying greater at higher levels of learning problems and agreement for victimization lower at higher levels of moodiness. The results indicate biases in rater perspective of student behavior and continue to support the need for multiple raters of student functioning.

Transformational Leadership Moderates the Relationship Between Emotional Exhaustion and Turnover Intention Among Community Mental Health Providers

Public sector mental health care providers are at high risk for burnout and emotional exhaustion which negatively affect job performance and client satisfaction with services. Few studies have examined ways to reduce these associations, but transformational leadership may have a positive effect. We examine the relationships between transformational leadership, emotional exhaustion, and turnover intention in a sample of 388 community mental health providers. Emotional exhaustion was positively related to turnover intention, and transformational leadership was negatively related to both emotional exhaustion and turnover intention. Transformational leadership moderated the relationship between emotional exhaustion and turnover intention, indicating that having a transformational leader may buffer the effects of providers’ emotional exhaustion on turnover intention. Investing in transformational leadership development for supervisors could reduce emotional exhaustion and turnover among public sector mental health providers.

A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping

BackgroundThe goal of this study was to assess potential differences between administrators/policymakers and those involved in direct practice regarding factors believed to be barriers or facilitating factors to evidence-based practice (EBP) implementation in a large public mental health service system in the United States.MethodsParticipants included mental health system county officials, agency directors, program managers, clinical staff, administrative staff, and consumers. As part of concept mapping procedures, brainstorming groups were conducted with each target group to identify specific factors believed to be barriers or facilitating factors to EBP implementation in a large public mental health system. Statements were sorted by similarity and rated by each participant in regard to their perceived importance and changeability. Multidimensional scaling, cluster analysis, descriptive statistics and t-tests were used to analyze the data.ResultsA total of 105 statements were distilled into 14 clusters using concept-mapping procedures. Perceptions of importance of factors affecting EBP implementation varied between the two groups, with those involved in direct practice assigning significantly higher ratings to the importance of Clinical Perceptions and the impact of EBP implementation on clinical practice. Consistent with previous studies, financial concerns (costs, funding) were rated among the most important and least likely to change by both groups.ConclusionsEBP implementation is a complex process, and different stakeholders may hold different opinions regarding the relative importance of the impact of EBP implementation. Implementation efforts must include input from stakeholders at multiple levels to bring divergent and convergent perspectives to light.

Predicting Delinquency in Adolescence and Young Adulthood A Longitudinal Analysis of Early Risk Factors

This study examined the ability of early risk factors to predict delinquency referrals. Significant risk factors included externalizing behaviors, prenatal smoking, parent marital status, and mothers education. Students with three or more risk factors had eight times the number of delinquency referrals than those with no identified risk factors.

The roles of individual and organizational factors in burnout among community-based mental health service providers.

Public-sector mental health care providers are at high risk for burnout, which negatively affects not only provider well-being but also the quality of services for clients and the functioning of organizations. This study examines the influence of demographics, work characteristic, and organizational variables on levels of burnout among child and adolescent mental health service providers operating within a public-sector mental health service system. Additionally, given the dearth of research examining differences in burnout levels among mental health subdisciplines (e.g., social work, psychology, marital and family therapy) and mental health programs (e.g., outpatient, day treatment, wraparound, case management), analyses were conducted to compare levels of burnout among multiple mental health disciplines and program types. Surveys were completed by 285 providers across 49 mental health programs in a large urban public mental health system. Variables representing dimensions of organizational climate and transformational leadership accounted for the greatest amount of variance in provider reported burnout. Analyses demonstrated significantly lower levels of depersonalization among wraparound providers compared to traditional case managers. Age was the only demographic variable related to burnout. Additionally, no significant effects were found for provider discipline or for agency tenure and caseload size. Results suggest the need to consider organizational development strategies aimed at creating more functional and less stressful climates and increasing levels of transformational leadership behaviors in order to reduce levels of burnout among clinicians working in public mental health settings for youth and families.

Adaptation happens: a qualitative case study of implementation of The Incredible Years evidence‐based parent training programme in a residential substance abuse treatment programme

Purpose – Evidence‐based practices (EBPs) are increasingly being implemented in real‐world settings. While intervention effectiveness is dependent on fidelity, interventions are often adapted to service settings according to the needs of stakeholders at multiple levels. This study aims to examine the naturalistic implementation of The Incredible Years (IY) parenting programme in a residential substance abuse treatment programme for pregnant and parenting women.Design/methodology/approach – The study took place in a residential substance abuse treatment programme serving pregnant and parenting women and their children. Participants included 120 female clients. The primary IY facilitator was a masters level counselling psychologist. In person observations of IY sessions were completed by a trained bachelors level anthropologist. Ethnographic field notes were collected and then coded in keeping with a priori themes and to identify emergent themes. The Parent Group Leader Checklist was used to evaluate qual...

From a "perfect storm" to "smooth sailing": policymaker perspectives on implementation and sustainment of an evidence-based practice in two states.

Policymakers shape implementation and sustainment of evidence-based practices (EBPs), whether they are developing or responding to legislation and policies or negotiating public sector resource constraints. As part of a large mixed-method study, we conducted qualitative interviews with 24 policymakers involved in delivery of the same EBP in two U.S. states. We analyzed transcripts via open and focused coding techniques to identify the commonality, diversity, and complexity of implementation challenges; approaches to overcoming those challenges; and the importance of system-level contextual factors in ensuring successful implementation. Key findings centered on building support and leadership for EBPs; funding and contractual strategies; partnering with stakeholders; tackling challenges via proactive planning and problem solving; and the political, legal, and systemic pressures affecting EBP longevity. The policymaker perspectives offer guidance on nurturing system and organizational practice environments to achieve positive outcomes and for optimally addressing macro-level influences that bear upon the instantiation of EBPs in public sector child welfare systems.

Mixed-method study of a conceptual model of evidence-based intervention sustainment across multiple public-sector service settings.

BackgroundThis study examines sustainment of an EBI implemented in 11 United States service systems across two states, and delivered in 87 counties. The aims are to 1) determine the impact of state and county policies and contracting on EBI provision and sustainment; 2) investigate the role of public, private, and academic relationships and collaboration in long-term EBI sustainment; 3) assess organizational and provider factors that affect EBI reach/penetration, fidelity, and organizational sustainment climate; and 4) integrate findings through a collaborative process involving the investigative team, consultants, and system and community-based organization (CBO) stakeholders in order to further develop and refine a conceptual model of sustainment to guide future research and provide a resource for service systems to prepare for sustainment as the ultimate goal of the implementation process.MethodsA mixed-method prospective and retrospective design will be used. Semi-structured individual and group interviews will be used to collect information regarding influences on EBI sustainment including policies, attitudes, and practices; organizational factors and external policies affecting model implementation; involvement of or collaboration with other stakeholders; and outer- and inner-contextual supports that facilitate ongoing EBI sustainment. Document review (e.g., legislation, executive orders, regulations, monitoring data, annual reports, agendas and meeting minutes) will be used to examine the roles of state, county, and local policies in EBI sustainment. Quantitative measures will be collected via administrative data and web surveys to assess EBI reach/penetration, staff turnover, EBI model fidelity, organizational culture and climate, work attitudes, implementation leadership, sustainment climate, attitudes toward EBIs, program sustainment, and level of institutionalization. Hierarchical linear modeling will be used for quantitative analyses. Qualitative analyses will be tailored to each of the qualitative methods (e.g., document review, interviews). Qualitative and quantitative approaches will be integrated through an inclusive process that values stakeholder perspectives.DiscussionThe study of sustainment is critical to capitalizing on and benefiting from the time and fiscal investments in EBI implementation. Sustainment is also critical to realizing broad public health impact of EBI implementation. The present study takes a comprehensive mixed-method approach to understanding sustainment and refining a conceptual model of sustainment.