Expect The Unexpected: A Qualitative Study of The Ripple Effects of Children’s Mental Health Services Implementation Efforts

Abstract

Background: Strategies to implement evidence-based interventions (EBIs) in children’s mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects as outcomes that are caused by EBI implementation efforts and are indirect, unplanned, unanticipated, and/or more salient to stakeholders other than to researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children’s mental health services, to be used for treatment development, implementation planning, research, and quality improvement.Methods: Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregiver, and youth. Participants brainstormed possible ripple effects. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. Results: Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Example categories include general knowledge, skills, attitudes, and confidence about using EBI’s; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one’s own life.Conclusions: This research advances the field by providing implementers, researchers, funders, policy makers, and consumers with a “menu” of potential ripple effects for consideration when evaluating the full balance of any implementation effort. It can be a practical tool to ensure compliance with the guidance of experts from Quality Improvement/Quality Assurance, Complexity Science, Diffusion of Innovation Theory, and the Medical Research Council. Future phases will match potential ripple effects with the most salient implementation strategies for each participant role.Trial Registration: None.