1. Chapter 6: Dissemination and Implementation of Evidence-Based Treatments for Children and Adolescents Michael A. Southam-Gerow Cassidy C. Arnold Carrie B. Tully Julia Revillion Cox

2. Key Terms Diffusion: planned or unplanned/spontaneous spread of an innovation, the natural distribution of new ideas as well as the more intentional spread of that idea Dissemination: the directed and planned spread of an innovation Implementation: processes and strategies needed to adapt the innovation Technology transfer: process of taking scientific findings and adapting them to have broader applications for public use and/or for sale in the commercial section Translational research: work that translates “bench science” to the bedside (and vice versa)

3. Why Is D&I Science Needed? Dissemination and Implementation (D&I) has emerged because of the need to identify ways to implement EBTs in a variety of settings Multiple factors impact how well a treatment works in a particular setting: Child and family factors Therapist factors Organization factors Service system factors

4. Barriers to Dissemination: Child and Family Factors In the community setting (vs. university setting): Impaired academic and social functioning of the child Other stressors Parents with less education Lower-income families Single-parent families Higher rates of trauma Higher rates of past suicide attempts

5. Barriers to Dissemination: Therapist Factors Efficacy studies often use therapists who are specially trained and receive ongoing supervision and consultation (e.g., doctoral-level students) Master-level therapists comprise the workforce in community mental health settings Can have concerns that manualized treatments are inflexible and inhibit individualized case conceptualization and treatment planning Limited specialized training in EBTs

6. Barriers to Dissemination: Organizational Factors Therapists within the community are often part of an agency or organization each with its own unique characteristics and culture that can influence successful implementation Organizational climate and policies drive clinician behavior; for successful implementation: 1. Goal-setting, planning, task operationalization 2. Involving other stakeholders in EBT selection 3. Creating an “implementation task force” 4. Involving consultants and reinforce organizational change 5. Allocating resources for implementation tasks 6. Integrating implementation goals into human resource sectors 7. Facilitating the training and development of management and support staff 8. Committing resources to support ongoing implementation activities

7. Barriers to Dissemination: System Factors System-level or outer context (Aarons et al. 2011) Relevant local, state, federal policy Availability and priorities of funding sources (e.g., public and private insurance, community resources) Referral mechanisms Legal obligations or mandates Relationships with other agencies and organizations Needs of local health consumers

8. Rogers’s Diffusion of Innovations Model Defined: Spreading an idea, practice, or object that is new or perceived to be new to the unit of adoption (e.g., individuals, therapists) through a social system Diffusion: the ways an idea moves through a social system via communication between parts or individuals within the social system Four primary factors emphasized: 1. Innovation and its characteristics 2. Channels of communication within the social system 3. Time 4. Social system Although not originally designed with mental health services in mind, Rogers’s model has important implications for D&I efforts

9. Fixsen et al.’s Implementation Framework Model for implementation occurs within the context of a specific community (e.g., agency, city) that has unique needs, assets, and challenges Five essential components of the model: 1. Source: innovation needs to be implemented as originally conceived by the developers 2. Destination: individual professional and the community implement the programs and the practices 3. Communication link: those individuals who actively work to efficiently implement a defined innovation with fidelity 4. Feedback mechanisms: ongoing mechanisms that provide each level of the organization with feedback

10. Mental Health Systems Ecological Model Developed for children’s mental health services Model outlines important levels of the ecology to consider when planning D&I science (e.g., child/family factors, therapist factors, organization factors) Implementation efforts should be designed with the key variables at one or more of these ecological levels in mind

11. Proctor et al.’s Implementation Research Model Proposed a nonlinear movement through D&I stages Model addresses multilevel nature of the forces on D&I by accounting for the information of variable at four levels: 1. Large system/environment 2. Organization 3. Group/team 4. Individual Includes multiple outcome domains

12. Multilevel, MultiPhase Implementation Model Four phases to guide D&I science: Exploration Adoption Decision/Preparation Implementation Sustainment Within each phase, emphasis is placed on the importance of specific factors across an ecological mode: outer context, inner context, innerconnections between outer and inner contexts

13. Quality Implementation Framework Model contains 14 critical steps across four phases (Meyers et al., 2012) Phase I: Initial considerations regarding the host setting I.e., preparation phase Phase 2: Implementation of innovation begins Phase 3: Set of steps to build lasting organizational structures with the goal of sustaining implementation Phase 4: Requires that the implementation team reflect on the results of the first three phases Model synthesizes broad literature to create model

14. Examples of EBT Implementation Research Research Network on Youth Mental Health Care Child System and Treatment Enhancement Projects (Child STEPs) Goal: bridge science-practice gap in children’s mental health, in part by developing and testing dissemination strategies Used a broad conceptual framework that examined elements that interact with the mental health system Governance structures, financing structures, reimbursement, provider organizations, clinical supervisors and clinicians, treatment and service content

15. Clinic Treatment Project (CTP) Part of Child STEPs Randomized controlled trial designed to ascertain whether modularized EBT would produce superior outcomes in a community setting compared to standard manual treatment/usual care Focus: children and adolescents with anxiety, depression, and disruptive behavior problems Three broad treatment groups: 1) modular manualized treatment, 2) standard manualized treatment, 3) usual care Found that the design of the treatment (i.e., allowing for flexibility) may influence not only the therapist perception of the intervention but the outcomes achieved

16. Role of Training/Supervision of Therapists Chamberlain et al. (2008) Study focused on the supervisor’s role in using a cascading training model to implement a multidimensional training for foster care parents Tested transferability of Multidimensional Treatment Foster Care (MTFC) from a research- based setting to foster parents in San Diego County

17. MTFC Three phases 1) Treatment developers supervised experienced foster parents who delivered treatment to foster family participants 2) Paraprofessionals provided the training with weekly in-person supervision from an on-site supervisor and phone supervision from a clinical consultant treatment developer 3) Paraprofessionals from staff from phase 2 trained a new cohort of paraprofessionals, there was no direct contact between the treatment developers and the second cohort of interventionists

18. Organizational Level Demonstrated the influence of organizational characteristics like organizational climate and organizational culture on D&I efforts E.g., Glisson et al. (2010): tested the benefits of an organizational intervention implementing an EBT in community-based mental health services in rural Tennessee Study designed to address barriers between a specific community and specific mental health service technology by focusing the community on the problem area, building community support for change, creating alliances between providers and stakeholders, and developing a social context for effective services

19. Conclusion Critical challenge of mental health care is how to best leverage the evidence base we have accumulated D&I represents an excellent path forward in this direction All D&I models explicitly or implicitly involve measurement of various processes relevant to implementation Many measures exist to assess key variables of interest (e.g., child symptoms and functioning, parent and family characteristics) Yet, measurement remains a key gap in the D&I literature Literature stresses the importance of implementation efforts that utilize collaboration with stakeholders