This study examined caregiver strain in families who initiated mental health services for their child. Predictors of strain and the bidirectional relation between strain and child symptoms were examined. Participants included 218 children ages 4-13 with disruptive behavior problems and their caregivers, plus 96 psychotherapists, recruited from six publicly-funded clinics. Child disruptive behavior severity and caregiver strain were assessed at baseline, four, and eight months. Multilevel models were used to examine predictors of reduced caregiver strain, and autoregressive cross-lagged models were used to examine the bidirectional relations between change in caregiver strain and behavior problems over time. There were small to medium decreases in caregiver strain over the eight months after the initiation of mental health services, but few factors predicted change other than initial behavior problem severity. While more severe initial child symptoms predicted greater reductions in caregiver strain, greater child symptom severity sustained at four months predicted lesser improvements in caregiver strain. Simultaneously, greater caregiver strain predicted less improvement in child symptom severity, suggesting that child symptom severity and caregiver strain impact each other over time. These results suggest that attending to both child and caregiver factors may be important in maintaining improvements after initiating usual care.

Naturalistic developmental behavioral interventions include an explicit focus on coaching parents to use therapy techniques in daily routines and are considered best practice for young children with autism. Unfortunately, these approaches are not widely used in community settings, possibly due to the clinical expertise and training required. This article presents the work of the Bond, Regulate, Interact, Develop, Guide, Engage (BRIDGE Collaborative), a multidisciplinary group of service providers (including speech-language pathologists), parents, funding agency representatives, and researchers dedicated to improving the lives of young children with autism spectrum disorder and their families. The group selected and adapted a parent coaching naturalistic developmental behavioral intervention specifically for use with toddlers and their families for community implementation. Lessons learned from the implementation process include the importance of therapist background knowledge, the complexity of working with parents of young children, and needed supports for those working closely with parents, including specific engagement strategies and the incorporation of reflective practice.

An Individualized Mental Health Intervention for ASD, ("AIM HI"), is a collaborative, caregiver-mediated and child-directed intervention for reducing challenging behaviors in children with autism spectrum disorder developed for delivery in community mental health programs. Using observational data from AIM HI sessions, the present study characterized the occurrence of two types of in-session caregiver behaviors: expressed concerns (i.e., expressing concerns about treatment strategies; expressing difficulty using skills; expressing difficulty completing homework) and participation engagement (i.e., asking questions; participating in session activities; showing commitment to therapy). Further analyses examined cultural differences in caregiver behaviors and associations between caregiver behaviors and clinician adherence. Participants included 39 caregiver-clinician dyads enrolled in a community effectiveness trial of AIM HI. Video recordings from 107 sessions during the first two months of treatment were coded for in-session caregiver behaviors and clinician adherence. Results indicated that expressed concerns were observed in 47% of sessions. When controlling for household income, Latinx caregivers were rated lower for expressing concerns about treatment strategies and demonstrated lower participation engagement behaviors in session compared with non-Latinx White caregivers, suggesting that cultural factors may impact verbal engagement in sessions. Finally, expressing concerns about treatment strategies, expressing difficulty using skills, and participation engagement were positively associated with clinician adherence. Findings suggest that some expressed concerns and participation engagement behaviors may be indicators of positive caregiver engagement in the context of a collaborative intervention, and lower levels of such caregiver engagement may actually impede clinicians' delivery of intensive evidence-based intervention in routine care.

Aims

Aims included (a) characterizing provider feedback on parent engagement strategies integrated into a parent-mediated intervention for toddlers at risk for autism spectrum disorder (ASD) and (b) identifying provider characteristics that predict attitudes about parent engagement strategies.

Methods

A mixed method approach was utilized, including gathering quantitative data via survey (breadth) and collecting qualitative data via interview (depth). Acceptability, utility, appropriateness, sustainment, generalizability, and perceived effectiveness were examined. Fourteen agency leaders and 24 therapists provided input.

Results

Providers perceived the integration of parent engagement strategies as having a positive impact on implementation. Providers considered the strategies to be acceptable, appropriate, and effective, though barriers of time and complexity were noted. Provider characteristics did not consistently predict attitudes about the engagement strategies.

Conclusions

Incorporating parent engagement strategies into parent-mediated interventions for ASD is well-received by providers and may improve quality of service delivery for families served in early intervention for ASD.

OBJECTIVES: Parent engagement poses a persistent challenge to home visitation (HV) programs. Previous work on parent engagement in HV has focused primarily on enrollment, attendance, and retention, with less attention on participation. The purpose of this study was to adapt an engagement toolkit originally developed for child mental health treatment settings, the Parent And Caregiver Active Participation Toolkit (PACT), and test the adapted toolkit in a HV program, SafeCare® (SC), with a focus on parent participation. METHODS: Toolkit adaptation was informed by interviews/focus groups with parents and home visitors. Next, home visitors (n = 6) were trained to use adapted PACT for SC as part of SC delivery to 18 parents. A comparison group included 24 parents who received SC one year prior to this study. Analyses compared PACT for SC participants to the comparison group on parent participation and home visitor fidelity to assignment of homework. Qualitative and quantitative data from parents, home visitors, and supervisors (n = 4) assessed the acceptability, utility, appropriateness, and feasibility of PACT for SC. RESULTS: Parents receiving PACT for SC had higher participation and reported greater home visitor fidelity to homework assignment than comparison parents. Parents found PACT for SC acceptable and useful as part of SC. Home visitors and supervisors identified some limitations in PACT for SCs utility but generally found it to be a positive, feasible addition to HV services. CONCLUSIONS: Results suggest that enhancing HV programs with an engagement toolkit may improve parents participation in services and providers assignment of homework between sessions.

Most of the knowledge generated to bridge the research-practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.

Parent participation in community-based child mental health services is an important yet understudied process associated with treatment effectiveness. This paper describes the development and psychometrics of the Parent Participation Engagement Measure in a sample of 1374 parents and 563 youth receiving publicly-funded mental health services. Analyses indicated excellent internal consistency, and model fit indices/factor loadings supported a one-factor model. Convergent and discriminant validity were supported, although some coefficients were modest in magnitude. Psychometric results were consistent for Caucasian versus Hispanic, parent versus youth, and English versus Spanish-language respondents. The clinical and research utility of this measure are discussed.

Lay abstract

Expert recommendations for toddlers who are likely to develop autism include caregivers being actively involved in the services children receive. However, many services available in the community may not follow these recommendations. Evidence suggests that an intervention named Project ImPACT for Toddlers demonstrates positive parent and child outcomes for families in the community. Project ImPACT for Toddlers was designed specifically for toddlers by a group of parents, clinicians, researchers, and funders. It teaches parents of young children strategies to support their child's development in daily routines. This study reports the perspectives of early intervention providers who learned to use Project ImPACT for Toddlers on whether the intervention was a good fit for their practice and easy to use. The study also examines how many agencies are using Project ImPACT for Toddlers and how many families have received the intervention in the community. The goal of the study is to inform the continued use of Project ImPACT for Toddlers in the community and support offering the intervention in other regions. Participants include 38 community providers who participated in a training study of Project ImPACT for Toddlers and completed a survey and semi-structured interview after approximately 3 months of using Project ImPACT for Toddlers with families. Participants perceived the training model as acceptable and appropriate, and identified the group-based model of training, comprehensive materials, and agency support as strengths of the approach. Survey findings complemented the results from the interviews. Data indicate an increasing number of agencies and families accessing Project ImPACT for Toddlers. Efforts to expand evidence-based intervention in early intervention should continue to build upon the model used for Project ImPACT for Toddlers.

The purpose of this review was to estimate the impact of parent engagement strategies tested with underrepresented families of young children with social, emotional, or behavioral disorders, and describe the combinations in which these strategies are commonly used together. We conducted a systematic review using the PracticeWise Engagement Coding System to identify which strategies had the strongest empirical support for engaging underrepresented (i.e., minority race or ethnicity, or low income) families receiving psychosocial services for their children. Social network analyses were used to identify the frequency of strategy use and how strategies were combined to engage underrepresented families. Linear regression was used to estimate the impact of each strategy on parent engagement, using attrition as a proxy for non-engagement. Thirty-five studies met inclusion criteria. Parent attrition was predicted by larger sample sizes, lower maternal education, interventions that were more community or home-based, less therapist monitoring, positive reinforcement from therapists, and more pairing families with peers. Social network analyses suggested that more effective strategies were more frequently implemented alone and less effective strategies were commonly combined with each other. Our findings suggest that researchers and practitioners require guidance in selecting engagement strategies to reduce attrition of underrepresented families in treatment. Although we identified promising strategies for improving parent engagement in treatment for underrepresented children with social, emotional, or behavioral disorders, the frequent combining of engagement strategies in research means that there is little data on the independent effects of interventions to increase parent engagement for this population.