Chapter 6: Dissemination and Implementation of

Evidence-Based Treatments for Children and

Adolescents

Michael A. Southam-GerowCassidy C. Arnold

Carrie B. TullyJulia Revillion Cox

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)

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 factorsTherapist factorsOrganization factorsService system factors

Barriers to Dissemination: Child and Family Factors

In the community setting (vs. university setting): Impaired academic and social functioning of the childOther stressorsParents with less educationLower-income familiesSingle-parent familiesHigher rates of traumaHigher rates of past suicide attempts

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 settingsCan have concerns that manualized treatments are

inflexible and inhibit individualized case conceptualization and treatment planning

Limited specialized training in EBTs

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 operationalization2. Involving other stakeholders in EBT selection3. Creating an “implementation task force”4. Involving consultants and reinforce organizational change5. Allocating resources for implementation tasks6. Integrating implementation goals into human resource sectors7. Facilitating the training and development of management and support

staff8. Committing resources to support ongoing implementation activities

Barriers to Dissemination: System Factors

System-level or outer context (Aarons et al. 2011)Relevant local, state, federal policyAvailability and priorities of funding sources (e.g.,

public and private insurance, community resources)

Referral mechanismsLegal obligations or mandatesRelationships with other agencies and

organizationsNeeds of local health consumers

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

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 developers2. Destination: individual professional and the community

implement the programs and the practices3. Communication link: those individuals who actively work

to efficiently implement a defined innovation with fidelity4. Feedback mechanisms: ongoing mechanisms that provide

each level of the organization with feedback

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

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/environment2. Organization3. Group/team4. Individual

Includes multiple outcome domains

Multilevel, MultiPhase Implementation Model

Four phases to guide D&I science: ExplorationAdoption Decision/PreparationImplementationSustainment

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

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 beginsPhase 3: Set of steps to build lasting organizational

structures with the goal of sustaining implementationPhase 4: Requires that the implementation team reflect

on the results of the first three phases

Model synthesizes broad literature to create model

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 systemGovernance structures, financing structures, reimbursement,

provider organizations, clinical supervisors and clinicians, treatment and service content

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

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

MTFC

Three phases1) 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

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

Conclusion

Critical challenge of mental health care is how to best leverage the evidence base we have accumulatedD&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