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

Eliminating Monitor Overuse (EMO) Type III Effectiveness-Deimplementation Cluster-Randomized Trial: Statistical Analysis Plan

Background: Deimplementing overused health interventions is essential to maximizing quality and value while minimizing harm, waste, and inefficiencies. Three national guidelines discourage continuous pulse oximetry (SpO2) monitoring in children who are not receiving supplemental oxygen, but the guideline-discordant practice remains prevalent, making it a prime target for deimplementation. This paper details the statistical analysis plan for the Eliminating Monitor Overuse (EMO) SpO2 trial, which compares the effect of two competing deimplementation strategies (unlearning only vs. unlearning plus substitution) on the sustainment of deimplementation of SpO2 monitoring in children with bronchiolitis who are in room air. Methods: The EMO Trial is a hybrid type 3 effectiveness-deimplementation trial with a longitudinal cluster-randomized design, conducted in Pediatric Research in Inpatient Settings Network hospitals. The primary outcome is deimplementation sustainment, analyzed as a longitudinal difference-in-differences comparison between study arms. This analysis will use generalized hierarchical mixed-effects models for longitudinal clustering outcomes. Secondary outcomes include the length of hospital stay and oxygen supplementation duration, modeled using linear mixed-effects regressions. Using the well-established counterfactual approach, we will also perform a mediation analysis of hospital-level mechanistic measures on the association between the deimplementation strategy and the sustainment outcome. Discussion: We anticipate that the EMO Trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, and likelihood of sustained practice change using rigorously designed deimplementation strategies. This pre-specified statistical analysis plan will mitigate reporting bias and support data-driven approaches

Applying the Policy Ecology Framework to Philadelphia’s Behavioral Health Transformation Efforts

Raghavan et al. (Implement Sci 3(26):1-9, 2008) proposed that effective implementation of evidence-based practices requires implementation strategies deployed at multiple levels of the "policy ecology," including the organizational, regulatory or purchaser agency, political, and social levels. However, much of implementation research and practice targets providers without accounting for contextual factors that may influence provider behavior. This paper examines Philadelphia's efforts to work toward an evidence-based and recovery-oriented behavioral health system, and uses the policy ecology framework to illustrate how multifaceted, multilevel implementation strategies can facilitate the widespread implementation of evidence-based practices. Ongoing challenges and implications for research and practice are discussed

A Prospective Examination of Clinician and Supervisor Turnover Within the Context of Implementation of Evidence-Based Practices in a Publicly-Funded Mental Health System

Staff turnover rates in publicly-funded mental health settings are high. We investigated staff and organizational predictors of turnover in a sample of individuals working in an urban public mental health system that has engaged in a system-level effort to implement evidence-based practices. Additionally, we interviewed staff to understand reasons for turnover. Greater staff burnout predicted increased turnover, more openness toward new practices predicted retention, and more professional recognition predicted increased turnover. Staff reported leaving their organizations because of personal, organizational, and financial reasons; just over half of staff that left their organization stayed in the public mental health sector. Implications include an imperative to focus on turnover, with a particular emphasis on ameliorating staff burnout

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

BACKGROUND: Insights from behavioral economics, or how individuals\u27 decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., Nudge ) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? METHODS: The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians\u27 use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. DISCUSSION: The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04844021 . Registered 14 April 2021

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

Diseño de un manual de detección de ansiedad social en adolescentes

Curso de Especial InterésEl objetivo de este trabajo de grado ha sido diseñar un manual dirigido a padres y docentes, en el que se establezcan técnicas de detección de ansiedad social en adolescentes; el diseño de este manual permite un aprendizaje significativo de una forma diferente, en un lenguaje claro y preciso, en formato digital para un fácil acceso y portabilidad del material, logrando de esta forma, que la población adolescente sea beneficiada a través de las acciones que se emprenderán por parte de los padres de familia, docentes y profesionales.142 p.RESUMEN 1. JUSTIFICACIÓN 2. OBJETIVOS 3. ESTUDIO DEL MERCADO 4. PRESENTACIÓN DEL PRODUCTO 5. CLIENTES – SEGMENTACIÓN 6. COMPETENCIA 7. CANALES DE DISTRIBUCIÓN 8. RESULTADOS DEL ESTUDIO DE MERCADO 9. DISCUSIÓN DEL ESTUDIO DE MERCADO 10. PRESUPUESTO 11. RESULTADOS 12. CONCLUSIONES REFERENCIAS APÉNDICESPregradoPsicólog

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science

It is well documented that the majority of adults, children and families in need of evidence-based behavioral health interventionsi do not receive them [1, 2] and that few robust empirically supported methods for implementing evidence-based practices (EBPs) exist. The Society for Implementation Research Collaboration (SIRC) represents a burgeoning effort to advance the innovation and rigor of implementation research and is uniquely focused on bringing together researchers and stakeholders committed to evaluating the implementation of complex evidence-based behavioral health interventions. Through its diverse activities and membership, SIRC aims to foster the promise of implementation research to better serve the behavioral health needs of the population by identifying rigorous, relevant, and efficient strategies that successfully transfer scientific evidence to clinical knowledge for use in real world settings [3]. SIRC began as a National Institute of Mental Health (NIMH)-funded conference series in 2010 (previously titled the “Seattle Implementation Research Conference”; $150,000 USD for 3 conferences in 2011, 2013, and 2015) with the recognition that there were multiple researchers and stakeholdersi working in parallel on innovative implementation science projects in behavioral health, but that formal channels for communicating and collaborating with one another were relatively unavailable. There was a significant need for a forum within which implementation researchers and stakeholders could learn from one another, refine approaches to science and practice, and develop an implementation research agenda using common measures, methods, and research principles to improve both the frequency and quality with which behavioral health treatment implementation is evaluated. SIRC’s membership growth is a testament to this identified need with more than 1000 members from 2011 to the present.ii SIRC’s primary objectives are to: (1) foster communication and collaboration across diverse groups, including implementation researchers, intermediariesi, as well as community stakeholders (SIRC uses the term “EBP champions” for these groups) – and to do so across multiple career levels (e.g., students, early career faculty, established investigators); and (2) enhance and disseminate rigorous measures and methodologies for implementing EBPs and evaluating EBP implementation efforts. These objectives are well aligned with Glasgow and colleagues’ [4] five core tenets deemed critical for advancing implementation science: collaboration, efficiency and speed, rigor and relevance, improved capacity, and cumulative knowledge. SIRC advances these objectives and tenets through in-person conferences, which bring together multidisciplinary implementation researchers and those implementing evidence-based behavioral health interventions in the community to share their work and create professional connections and collaborations

Measurement of unnecessary psychiatric readmissions in the context of care transition interventions: a scoping review

Objective The objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.Design Scoping review using Levac et al’s enhancement to Arksey and O’Malley’s framework for conducting scoping reviews.Data sources Medline (Ovid), Embase (Ovid), PsycINFO, CINAHL, Cochrane and ISI Web of Science article databases were searched from 1 January 2009 through 28 February 2019.Eligibility criteria for selecting studies We included studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, the time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission).Data extraction and synthesis We assessed review findings through tabular and content analyses of the data extracted from included articles.Results Our database search yielded 3478 unique articles, 67 of which were included in our scoping review. The included articles varied widely in their reported readmission time intervals used. They provided limited details regarding which readmissions they considered unnecessary and which risks they accounted for in their measurement. There were no perceptible trends in associations between the variation in these findings and the included studies’ characteristics (eg, target population, type of care transition intervention).Conclusions The limited specification with which studies report their approach to unnecessary psychiatric readmissions measurement is a noteworthy gap identified by this scoping review, and one that can hinder both the replicability of conducted studies and adaptations of study methods by future investigations. Recommendations stemming from this review include (1) establishing a framework for reporting the measurement approach, (2) devising enhanced guidelines regarding which approaches to use in which circumstances and (3) examining how sensitive research findings are to the choice of the approach