Editorial: Implementation of evidence-based treatments for child anxiety and related disorders across diverse contexts

Youth anxiety and related disorders, such as obsessive-compulsive disorder and post-traumatic stress disorder, are prevalent (1), and on the rise (2). Ensuring that anxious youth receive timely and evidence-based treatment is critical; left untreated, these disorders are predictive of a host of future negative outcomes including continued or worsening anxiety, depression, substance abuse, and suicide (3–8). Unfortunately, it can take 15 years or more after a problem is recognized for someone with an anxiety or related disorder to connect with evidence-based psychosocial care, and most youth with anxiety who seek treatment will not receive effective care. This is in large part because as many as 90% of practicing mental health clinicians do not routinely deliver exposure-based cognitive behavioral therapy (Ex-CBT) to their clients struggling with anxiety (9–12), which is the gold-standard, first-line, evidence-based practice (EBP) for anxiety and related disorders (13). In other words, Ex-CBT demonstrates a major research to practice gap: while Ex-CBT is one of the treatments for which we have perhaps some of the strongest evidence for its efficacy and effectiveness, it remains one of the least used treatments within routine clinical care. Note we use the term Ex-CBT to refer to any CBT-based protocol that recognizes maladaptive anxious avoidance as a hallmark psychopathological characteristic of an anxiety or related disorder and works to minimize avoidance and safety-seeking behaviors through approach-oriented strategies (e.g., in vivo exposures, interoceptive exposure, exposure with response prevention, and prolonged exposure/trauma narratives). Using insights from implementation science, or the scientific study of how to increase the use of EBPs in routine clinical settings to improve care quality (14), the past few decades have seen advances in efforts to understand the major barriers leading to the underutilization of Ex-CBT. Identified barriers range from concerns about the complex nature of the intervention itself (15) and poor marketing of Ex-CBT to practicing clinicians and families (16), negative beliefs and misconceptions about Ex-CBT held by clinicians (17–20), organizational constraints and intervention delivery challenges (21, 22), and systemic barriers related to factors such as reimbursement rates and limited funding for specialized training (23). These implementation barriers also occur alongside historical underrepresentation of marginalized and minoritized individuals in clinical treatment trials and limited attention to ways of culturally tailoring treatments to increase engagement and effectiveness. Despite increased understanding of why Ex-CBT remains so underutilized, efforts to increase Ex-CBT delivery have had only limited or mixed success (10, 24, 25) or remain in early stages of pilot testing (26, 27). This Research Topic is intended to further advance understanding of how to improve implementation of Ex-CBT for pediatric anxiety and related disorders across the diverse contexts in which youth may receive care, such as outpatient mental health, primary care, and schools. The varied topics published in this special Research Topic highlight the many ways that researchers are attempting to address the challenge of how to ensure youth with anxiety and related disorders receive the highest quality treatment service. Several articles in this series focus specifically on the need to adapt existing models of Ex-CBT to better fit non-specialty contexts as well as better align the content and format of treatment to address the needs of youth who historically have not been well-represented in clinical trials (e.g., those of historically minoritized identities, those with complex comorbidities). For example, Kendall et al. describe how the various ways a single Ex-CBT protocol—the Coping Cat program (28)—can be adapted in a myriad of ways to improve implementation fit across clinical settings. In contrast, Herres et al. posit that Ex-CBT protocols likely need to be integrated with other treatments drawn from family systems protocols to truly address the complex symptom presentation that many youth present with in community settings. Building on work by others suggesting we should be co-developing novel protocols in tandem with local context leaders to enhance implementabilty and scalability of treatments (29), rather than relying on extant protocols, Gellatly et al. describe the complexity of this process, underscoring the need to collaborate with local context leaders and the critical importance of cultural and contextual considerations to support successful protocol design. Underscoring the importance of treatment adaptation research is work led by Lawson et al. empirically demonstrating the cost-effectiveness of a culturally adapted version of school-based Ex-CBT relative to an unadapted Ex-CBT model. In an alternative approach, Frank et al. highlight the importance of speaking with caregivers of anxious youth to understand the family experience of trying to access Ex-CBT. Their work suggested several promising implementation strategies targeted directly to consumers that could expedite families\u27 access to quality services. Remaining studies in this Research Topic focused directly on how to best support clinicians to deliver Ex-CBT with fidelity to optimize outcomes. Meza et al. highlight specific supervisory strategies that are associated with improved clinician delivery of exposure-based techniques for youth experiencing symptoms of post-traumatic stress, while Kemp et al. discuss the potential of a novel experiential training strategy (“exposure to exposure”) to directly address the negative beliefs many clinicians hold about Ex-CBT. Taken together, this Research Topic highlights the importance of adapting Ex-CBT protocols to improve their cultural responsiveness and implementation fit, the critical importance of including patient and family voices in designing implementation strategies to improve Ex-CBT uptake, and the continued need for testing novel strategies that directly address known barriers to Ex-CBT implementation. At the same time, this Research Topic highlights the extraordinary amount of remaining work to be done to truly increase the accessibility and effectiveness of Ex-CBT to all youth who could benefit. In particular, the field will benefit from increasing clarity on how to optimize the cultural responsiveness of Ex-CBT and how and when to sequence Ex-CBT with other treatment models to optimize innovation fit to the increasingly varied settings in which youth seek treatment. This Research Topic also highlighted several promising implementation strategies (e.g., targeted supervisory support, exposure to exposure) ripe for testing in confirmatory hybrid effectiveness-implementation trials. Given the current children\u27s mental health crisis (30), we urge a continued focus on research in this area to alleviate the distress and burden experienced by anxious youth and their families

Testing a Theory of Strategic Implementation Leadership, Implementation Climate, and Clinicians’ Use of Evidence-Based Practice: A 5-Year Panel Analysis

Background: Implementation theory suggests that first-level leaders, sometimes referred to as middle managers, can increase clinicians’ use of evidence-based practice (EBP) in healthcare settings by enacting specific leadership behaviors (i.e., proactive, knowledgeable, supportive, perseverant with regard to implementation) that develop an EBP implementation climate within the organization; however, longitudinal and quasi-experimental studies are needed to test this hypothesis. Methods: Using data collected at three waves over a 5-year period from a panel of 30 outpatient children’s mental health clinics employing 496 clinicians, we conducted a quasi-experimental difference-in-differences study to test whether within-organization change in implementation leadership predicted within-organization change in EBP implementation climate, and whether change in EBP implementation climate predicted within-organization change in clinicians’ use of EBP. At each wave, clinicians reported on their first-level leaders’ implementation leadership, their organization’s EBP implementation climate, and their use of both EBP and non-EBP psychotherapy techniques for childhood psychiatric disorders. Hypotheses were tested using econometric two-way fixed effects regression models at the organization level which controlled for all stable organizational characteristics, population trends in the outcomes over time, and time-varying covariates. Results: Organizations that improved from low to high levels of implementation leadership experienced significantly greater increases in their level of EBP implementation climate (d = .92, p = .017) and within-organization increases in implementation leadership accounted for 11% of the variance in improvement in EBP implementation climate beyond all other covariates. In turn, organizations that improved from low to high levels of EBP implementation climate experienced significantly greater increases in their clinicians’ average EBP use (d = .55, p = .007) and within-organization improvement in EBP implementation climate accounted for 14% of the variance in increased clinician EBP use. Mediation analyses indicated that improvement in implementation leadership had a significant indirect effect on clinicians’ EBP use via improvement in EBP implementation climate (d = .26, 95% CI [.02 to .59]). Conclusions: When first-level leaders increase their frequency of implementation leadership behaviors, organizational EBP implementation climate improves, which in turn contributes to increased EBP use by clinicians. Trials are needed to test strategies that target this implementation leadership–EBP implementation climate mechanism

A Randomized Trial to Identify Accurate and Cost-Effective Fidelity Measurement Methods for Cognitive-Behavioral Therapy: Project FACTS Study Protocol

Background: This randomized trial will compare three methods of assessing fidelity to cognitive-behavioral therapy (CBT) for youth to identify the most accurate and cost-effective method. The three methods include self-report (i.e., therapist completes a self-report measure on the CBT interventions used in session while circumventing some of the typical barriers to self-report), chart-stimulated recall (i.e., therapist reports on the CBT interventions used in session via an interview with a trained rater, and with the chart to assist him/her) and behavioral rehearsal (i.e., therapist demonstrates the CBT interventions used in session via a role-play with a trained rater). Direct observation will be used as the gold-standard comparison for each of the three methods. Methods/design: This trial will recruit 135 therapists in approximately 12 community agencies in the City of Philadelphia. Therapists will be randomized to one of the three conditions. Each therapist will provide data from three unique sessions, for a total of 405 sessions. All sessions will be audio-recorded and coded using the Therapy Process Observational Coding System for Child Psychotherapy-Revised Strategies scale. This will enable comparison of each measurement approach to direct observation of therapist session behavior to determine which most accurately assesses fidelity. Cost data associated with each method will be gathered. To gather stakeholder perspectives of each measurement method, we will use purposive sampling to recruit 12 therapists from each condition (total of 36 therapists) and 12 supervisors to participate in semi-structured qualitative interviews. Discussion: Results will provide needed information on how to accurately and cost-effectively measure therapist fidelity to CBT for youth, as well as important information about stakeholder perspectives with regard to each measurement method. Findings will inform fidelity measurement practices in future implementation studies as well as in clinical practice. Trial registration: NCT02820623, June 3rd, 2016

Implementing nudges for suicide prevention in real-world environments: project INSPIRE study protocol

Background: Suicide is a global health issue. There are a number of evidence-based practices for suicide screening, assessment, and intervention that are not routinely deployed in usual care settings. The goal of this study is to develop and test implementation strategies to facilitate evidence-based suicide screening, assessment, and intervention in two settings where individuals at risk for suicide are especially likely to present: primary care and specialty mental health care. We will leverage methods from behavioral economics, which involves understanding the many factors that influence human decision making, to inform strategy development. Methods: We will identify key mechanisms that limit implementation of evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health through contextual inquiry involving behavioral health and primary care clinicians. Second, we will use contextual inquiry results to systematically design a menu of behavioral economics-informed implementation strategies that cut across settings, in collaboration with an advisory board composed of key stakeholders (i.e., behavioral economists, clinicians, implementation scientists, and suicide prevention experts). Finally, we will conduct rapid-cycle trials to test and refine the menu of implementation strategies. Primary outcomes include clinician-reported feasibility and acceptability of the implementation strategies. Discussion: Findings will elucidate ways to address common and unique barriers to evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health care. Results will yield refined, pragmatically tested strategies that can inform larger confirmatory trials to combat the growing public health crisis of suicide

Anxiety and Atopic Disease: Comorbidity in a Youth Mental Health Setting

Anxiety frequently co-occurs with atopic diseases (e.g., allergies) in community samples, although data are limited to community and pediatric medical samples. Little work has examined atopy rates among mental health treatment seeking youth or whether youth with comorbid anxiety and atopy present similarly to non-comorbid youth. Using initial intake data from a University-based specialty youth clinic for anxiety and depressive disorders (n = 189), rates of atopic comorbidity were benchmarked against lifetime prevalence estimates in epidemiological samples. Anxiety severity and parental stress were compared between youth with and without atopy. Results indicated high rates of atopy in the clinical sample (51.3 %) relative to population atopy estimates (34.5 %). Anxious youth with atopy exhibited more overall and generalized anxiety symptoms relative to non-atopic youth (ps < .05); parental stress was comparable between atopic and non-atopic anxious youth. This suggests potentially heightened clinical severity for youth with co-occurring anxiety and atopy

Money makes the world go 'round: A qualitative examination of the role funding plays in large-scale implementation and sustainment of youth evidence-based practice

Funding is posited to affect evidence-based practice implementation, yet the complex interplay between financial matters and successful implementation is understudied. This study examined stakeholder perspectives on the impact of funding in evidence-based practice implementation. All participants were key stakeholders (e.g., clinicians, case managers, agency leaders; N = 41) involved in a trauma-focused cognitive-behavioral therapy implementation effort using a community-based learning collaborative model within the community's child welfare system. Semistructured interviews were conducted and qualitatively analyzed as part of a program evaluation of the implementation effort. Funding emerged as a key theme influencing implementation within this program evaluation from the perspective of all stakeholders. Thirty-four participants (83%) independently raised funding as an important factor affecting implementation outcomes across seven specific themes: (a) the impact of privatization, (b) turfism, (c) money as a primary implementation facilitator, (d) implementation costs impacting participation, (e) burden associated with funding evaluation efforts, (f) need for reimbursement practices to align with the use of trauma-informed treatment, and (g) a sense of shared mission to serve clients above money. Recommendations for addressing these challenges are provided. Future research should examine funding qualitatively and quantitatively across diverse communities and funding systems to improve understanding of the impact of funding on implementation and, ultimately, care provided to clients. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

What is the Status of Multi-Informant Treatment Fidelity Research?

The precise measurement of treatment fidelity (quantity and quality in the delivery of treatment strategies in an intervention) is essential for intervention development, evaluation, and implementation. Various informants are used in fidelity assessment (e.g., observers, practitioners [clinicians, teachers], clients), but these informants often do not agree on ratings. This scoping review aims to ascertain the state of science around multi-informant assessment of treatment fidelity. A literature search of articles published through December 2021 identified 673 articles. Screening reduced the number of articles to 44, and the final study set included 35 articles. There was substantial variability across studies regarding study design, how fidelity was operationalized, and how reliability was defined and assessed. Most studies evaluated the agreement between independent observers and practitioner-report, though several other informant pairs were assessed. Overall, findings suggest that concordance across fidelity informants was low to moderate, with a few key exceptions. It is difficult to draw clear conclusions about the degree to which single versus multiple informant assessment is needed to produce an accurate and complete picture of treatment fidelity. The field needs to take steps to determine how to leverage multi-informant assessment to accurately assess treatment fidelity

Parent-youth informant disagreement: Implications for youth anxiety treatment

Greater parent-youth disagreement on youth symptomatology is associated with a host of factors (e.g., parental psychopathology, family functioning) that might impede treatment. Parent-youth disagreement may represent an indicator of treatment prognosis. Using data from the Child/Adolescent Anxiety Multimodal Study, this study used polynomial regression and longitudinal growth modeling to examine whether parent-youth agreement prior to and throughout treatment predicted treatment outcomes (anxiety severity, youth functioning, responder status, and diagnostic remission, rated by an independent evaluator). When parents reported more symptoms than youth prior to treatment, youth were less likely to be diagnosis-free post-treatment; this was only true if the youth received cognitive-behavioral therapy (CBT) alone, not if youth received medication, combination, or placebo treatment. Increasing concordance between parents and youth over the course of treatment was associated with better treatment outcomes across all outcome measures ( ps < .001). How parents and youth "co-report" appears to be an indicator of CBT outcome. Clinical implications and future directions are discussed