Therapist Adaptations to a Package of Evidence-Based Strategies for Children with Autism Spectrum Disorder

Background: There is growing evidence that it is common for therapists to adapt evidence-based practices (EBP) protocols when implementing in routine mental health (MH) settings. Less is known, however, about the types, rationale, and implications of these adaptations on clinical and implementation outcomes (Wiltsey-Stirman, et al. 2015).

Objectives: This mixed-methods study examined the types and reasons therapists adapted AIM HI (“An Individualized Mental Health Intervention for ASD”), a package of evidence-based strategies designed for children with autism spectrum disorder served in publically-funded MH settings.

Methods: Quantitative (Therapist Adaptations to Practice Questionnaire (TAPQ)) and qualitative data (semi-structured interviews) were collected as part of a randomized effectiveness trial of AIM HI in which MH programs were randomized to immediate AIM HI training/implementation or wait-list control/routine care observation condition. TAPQ and semi-structured interviews were completed with a subgroup of therapists (n=51) from 14 MH programs following 6 months of AIM HI training/consultation. Emergent themes from qualitative data were used to complement and expand findings from the TAPQ characterizing the types of adaptations therapists report. .

Results: On the TAPQ, 95% of therapists reported that they made some adaptations to AIM HI, and the most common types of adaptations included: (1) integrating components of other treatments in the delivery of AIM HI (35% of therapists); (2) lengthening the pacing of an AIM HI protocol step (33%); (3) modifying the terminology or language/wording when describing AIM HI concepts/components (30%); and (4) involving other individuals (e.g., teachers) in the treatment process (26%). Less common adaptations included: (1) shortening the pacing of protocol steps (11%); (2) adjusting the order of the protocol steps (4%); (3) skipping protocol components (3%). The following were the most common reasons for adaptations: (1) intervention-client fit, including accommodating the child (48%) and caregivers’ (48%) clinical functioning or needs and increasing caregiver involvement in treatment (49%); and (2) intervention-provider fit, including consistency with the therapists’ previous clinical practice/style (28%). Preliminary themes from the qualitative interviews confirmed and expanded upon the most common adaptations and reasons for these adaptations. For example, therapists indicated that they often modified the AIM HI terminology to make concepts easier to understand for a range of caregiver characteristics (e.g., monolingual Spanish-speaking caregivers, those with lower education or literacy levels, and those with their own mental health/developmental challenges).

Conclusions: Results suggest that most therapists made adaptations to the AIM HI protocol. It is encouraging that adaptations were consistent with the AIM HI protocol, with the primary intent of enhancing the intervention to fit with therapeutic style and to address clients’/caregivers’ needs and functioning. These findings suggest that therapists are able to implement fidelity-consistent adaptations to the AIM HI protocol and provide insight into potential areas in which therapists would benefit from targeted training on how to systematically adapt the AIM HI protocol.