Training Community Mental Health Providers to Deliver an Intervention for Children with ASD: Impacts on Therapist Practice and Child Behaviors

Background:Publicly-funded mental health (MH) services play an important role in caring for school-age children with ASD. AIM HI (“An Individualized Mental Health Intervention for ASD”, Brookman-Frazee and Drahota, 2010) was developed based on a systematic needs assessment and in collaboration with community stakeholders in response to the need for a scalable intervention for delivery in MH programs. AIM HI is a package of well-established parent mediated and child-focused behavioral strategies designed to reduce challenging behaviors, the most common presenting problem for children with ASD in MH services. The current study examined the impact of training community therapists to deliver AIM HI. Data were drawn from a completed large-scale randomized community effectiveness trial of AIM HI conducted in publicly-funded outpatient and school-based MH programs.

Objectives: The purpose of this study was to examine the impact of training community MH therapists to delivery AIM HI to their clients on observed therapist practice and child behavior problems and to identify therapist perceptions and child factors associated with these outcomes.

Methods: A waitlist controlled design was used in which 29 MH programs were randomized to either immediate AIM HI training or Usual Care/Delayed AIM HI training conditions. Therapist and client dyads were recruited from with enrolled programs. A total of 202 client/therapist dyads were included. Therapists were 86% female and 33% Latino and children (M age = 9.1 years) were 82% male and 56% Latino. Session-level therapist fidelity was collected over the 6 month training period during which the therapist delivered AIM HI to their client while receiving performance feedback from an AIM HI trainer. Specifically, video recordings of 1,153 psychotherapy sessions were coded for adherence to active teaching strategies (e.g., modeling, behavioral rehearsal) directed to children and parents. Therapists reported on their confidence using active teaching strategies at baseline. The Eyberg Child Behavior Inventory (ECBI) was completed by parents at baseline, 6 months (post), and 12 and 18 month follow up.

Results: AIM HI adherence was significantly higher for therapists who received AIM HI training compared to Usual Care therapists (B=1.40, p<.001). Therapist self-reported pre-training confidence was associated with adherence directed to children (B=.17, p=.05). Results from three-level (time nested within child within program site) mixed effects modeling controlling for ASD severity and program setting (school, clinic) revealed a significant group by time interaction for ECBI Intensity scores (B=-0.38, p.015). Follow-up tests showed a significantly greater decline across the four time-points in the AIM HI training group (B=-1.36, p<.001) relative to the Usual Care group (B=-0.98, p<.001). Therapist AIM HI adherence and child behaviors in session significantly moderated this effect.

Conclusions: These results provide empirical support for the effectiveness of AIM HI on a key targeted outcome when delivered by community mental health providers and highlight the importance of therapist fidelity on outcomes. Next steps in the research include a recently-initiated, large scale implementation trial examining training and implementation leadership strategies to improve therapist fidelity.