Effectiveness of Training Therapists to Deliver An Individualized Mental Health Intervention for Children With ASD in Publicly Funded Mental Health Services

Abstract

IMPORTANCE Publicly funded mental health services play an important role in addressing co-occurring mental health problems in children with autism spectrum disorder (ASD); however, therapists report lacking training to effectively serve this complex population. OBJECTIVE To test the effectiveness of training community therapists in An Individualized Mental Health Intervention for ASD (AIM HI) on challenging behaviors across 18 months among children with ASD and identify moderators and mediators of any intervention effects. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial conducted in 29 publicly funded outpatient and school-based mental health programs in southern California from 2012 to 2017. Programs were randomized to receive immediate AIM HI training or provide usual care followed by receipt of AIM HI training. Therapist participants were recruited from enrolled programs, and child participants were recruited from participant therapists' caseloads. Data were analyzed from 202 children with ASD who were aged 5 to 13 years. INTERVENTIONS The AIM HI protocol is a package of parent-mediated and child-focused strategies aimed to reduce challenging behaviors in children with ASD who are 5 to 13 years old. It was designed for delivery in publicly funded mental health services based on a systematic assessment of therapist training needs and child clinical needs. The therapist training and consultation process takes approximately 6 months and includes an introductory workshop, 11 structured consultation meetings as the therapist delivers AIM HI with a current client, and case-specific performance feedback from trainers. MAIN OUTCOMES AND MEASURES Child participants were assessed for challenging behaviors using the Eyberg Child Behavior Inventory (ECBI) and Social Skills Improvement System (SSIS) Competing Problem Behaviors scales based on parent report at baseline and at 6-month intervals for 18 months. Outcomes were analyzed using intent-to-treat models. RESULTS In total, 202 children with ASD (mean [SD] age, 9.1 [2.4] years; 170 [84.2%] male; 121 [59.9%] Latinx) were eligible, enrolled, and included in the analyses. Statistically significant group by time interactions for the ECBI Intensity (B = −0.38; P = .02) and ECBI Problem (B = −1.00; P = .005) scales were observed, with significantly larger decreases in ECBI Intensity scores in the AIM HI group (B = −1.36; P < .001) relative to the usual care group (B = −0.98; P < .001) and a significantly larger decrease in ECBI Problem scores in the AIM HI group (B = −1.22; P < .001) relative to the usual care group (B = −0.20; P = .29). Therapist fidelity moderated these intervention effects. CONCLUSIONS AND RELEVANCE The present findings support the effectiveness of training therapists to deliver the AIM HI model to children with ASD receiving publicly funded mental health services.

Using stakeholder perspectives to guide systematic adaptation of an autism mental health intervention for Latinx families: A qualitative study

“…Data were collected from a supplemental disparities study (Chlebowski et al, ) embedded within a Hybrid Type 1 effectiveness‐implementation trial of AIM HI (Brookman‐Frazee et al, ). Qualitative methods were used to gather targeted recommendations for AIM HI adaptations from a subgroup of therapists and Latinx parents who participated in the trial.…”

“…Finally, any work considering EBI adaptations must acknowledge the tension that exists between tailoring interventions to improve fit and sustainment and maintaining fidelity to original EBI content (Cabassa & Baumann, ). This balance is particularly relevant for AIM HI, as therapist fidelity to the intervention moderated child outcomes (Brookman‐Frazee et al, ). Future work implementing the recommended adaptations will need to utilize systematic frameworks to ensure that adaptations are fidelity‐consistent and reflect the core elements of the intervention.…”

“…Results indicate that children whose therapists participated in AIM HI training and consultation showed significantly greater improvements in behaviors compared with children whose therapists did not receive AIM HI training and delivered usual care. These differences were mediated by therapist fidelity (Brookman‐Frazee, Roesch, Chlebowski, Baker‐Ericzen, & Ganger, ).…”

“…The AIM HI community effectiveness trial provided a unique avenue to address this need to obtain the perspectives of Latinx parents as 50% of parents and 58% of children in the intervention sample self‐identified as Latinx (Brookman‐Frazee et al, ). Implementation‐related study activities, including qualitative interviews with parents and therapists, were used to inform two goals: (a) Identify factors that may explain differences in AIM HI treatment process targets with a specific focus on exploration of cultural factors (e.g., acculturation and cultural beliefs about ASD symptoms, mental health services, and a parent's role in treatment) and (b) explore potential adaptations to the AIM HI intervention and training program to reduce disparities.…”

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

“…The iterative, community partnered and transdiagnostic (i.e., appropriate for a range of co-occurring psychiatric conditions) approach to develop and further refine AIM HI has been shown to increase therapist delivery of evidence-based strategies and improve child clinical outcomes [ 32 – 35 ]. Furthermore, AIM HI research highlights the relevance and utility of a transdiagnostic approach to improve clinical outcomes for a clinically challenging population of children with ASD receiving mental health services [ 36 , 37 ]. The current study extends AIM HI research by applying the community partnered, context-based approach to target a new transdiagnostic clinical mechanism.…”