Examining ethnic disparities in provider and parent in-session participation engagement

Abstract

Purpose

Well-documented ethnic disparities exist in the identification and provision of quality services among children receiving community-based mental health services. These disparities extend to parent treatment engagement, an important component of effective mental health services. Currently, little is known about differences in how providers support parents’ participation in treatment and the degree to which parents actively participate in it. The purpose of this paper is to examine potential differences in both provider and parent in-session participation behaviours.

Design/methodology/approach

Participants included 17 providers providing standard community-based mental health treatment for 18 parent-child dyads, with 44 per cent of the dyads self-identifying as Hispanic/Latino. In-session participation was measured with the parent participation engagement in child psychotherapy and therapist alliance, collaboration, and empowerment strategies observational coding systems.

Findings

Overall, results indicate significantly lower levels of parent participation behaviours among Hispanic/Latino families compared to their Non-Hispanic/Non-Latino counterparts. No significant differences were seen in providers’ in-session behaviours to support parent participation across Hispanic/Latino and Non-Hispanic/Non-Latino families.

Research limitations/implications

These findings contribute to the literature on ethnic differences in parent treatment engagement by utilising measures of in-session provider and parent behaviours and suggest that further investigation is warranted to documenting and understanding ethnic disparities in parents’ participation in community-based child mental health treatment.

Originality/value

This paper contributes to the evaluation of differences in parent treatment engagement through demonstrating the utility of an in-session observational coding system as a measure of treatment engagement.

Introduction

Racial and ethnic disparities exist in the identification and provision of quality healthcare services for youth and their families; this is especially prevalent for the access and receipt of mental health services for children from racial/ethnic minority backgrounds. For example, there is some evidence that Hispanic youth experience higher rates of certain mental health conditions, such as mood disorders, than their non-Hispanic White peers (Merikangas et al., 2010). Yet, Hispanic youth are less likely to be appropriately diagnosed or to receive mental health services, resulting in significant unmet mental health needs, defined as lack of mental health services despite the presence of functional impairment (Kataoka et al., 2002).

Underscoring this unmet need, it is estimated that fewer than 1 in 11 Hispanic individuals with mental health issues seek mental health services (Kataoka et al., 2002; US Departmemt of Health and Human Services, 2001). This lower utilisation in Hispanic individuals may be due to the significantly greater number of barriers encountered in accessing care, including being uninsured, difficulty obtaining timely services and referrals, and maintaining a consistent source of care (Flores, 2010; Garland et al., 2005). However, other factors specific to mental health may play a role. In a recent study exploring parent-reported barriers to child mental health treatment, Young and Rabiner (2015) found that Hispanic parents and caregivers (hereafter referred to as parents) reported significantly more barriers to treatment in general, including both logistical (e.g. distance to community clinic, health insurance limitations) and stigma-related barriers (e.g. reflecting poorly on parent, being marginalised by family and community members). Furthermore, they found that among parents, regardless of ethnicity, these barriers were especially preventative of obtaining mental health services. Among those who successfully access care, Hispanic families are more likely to receive less adequate or evidence-based care (Seid et al., 2003), including mental health care, compared to Caucasian children (Alexandre et al., 2009). These disparities are extremely concerning given data highlighting higher health, including mental health, needs among Hispanic children and their families (Flores, 2010).

Beyond initial utilisation, parent engagement in treatment is considered critically important to effective child psychotherapy (Dowell and Ogles, 2010; Karver et al., 2006; Nock and Kazdin, 2005) and has been linked to premature termination and drop-out (Nock and Ferriter, 2005) as well as symptom and impairment outcomes (Haine-Schlagel and Walsh, 2015). Parent engagement is typically conceptualised as consisting of attitudinal and behavioural dimensions. Attitudinal engagement refers to a client’s or parent’s commitment to and investment in treatment and behavioural engagement refers to client or parent behaviours that demonstrate engagement in the treatment (Haine-Schlagel and Walsh, 2015; Nock and Ferriter, 2005; Staudt, 2007). Within behavioural engagement, behaviours can be divided into two types: attendance engagement that encompasses attending services, and participation engagement that includes participating in in-session activities and discussions and adhering to treatment recommendations outside of sessions (Haine-Schlagel and Walsh, 2015; Nock and Ferriter, 2005; Staudt, 2007). Studies focused on the behavioural dimension of parent engagement suggest that targeting both attendance engagement and parent participation engagement (PPE) may improve treatment efficacy and decrease treatment barriers (Haine-Schlagel and Walsh, 2015; Kazdin and Whitley, 2003). In this sense, parent engagement may be an important mechanism impacting this disparity in the access and receipt of mental health services.

Although some attention has been paid in the literature to PPE, the majority of the extant research on parent engagement in child mental health treatment has focused on session attendance (Becker et al., 2015; Haine-Schlagel and Walsh, 2015; Lindsey et al., 2013; Nock and Ferriter, 2005; Staudt, 2007). Data suggest that while attendance is a necessary predictor of positive treatment outcomes, attendance does not reflect the active participation of parents in the treatment itself (Bamberger et al., 2011; Nix et al., 2009). For example, components of PPE, such as in-session discussion and adherence to home action recommendations or “homework”, provide proof of learning and generalisation of skills beyond what is represented by simply attending sessions (Becker et al., 2015). Further, data suggest that provider in-session behaviours significantly impact parent in-session behaviours, including parental acquisition of parenting techniques (Eames et al., 2010), suggesting that factors such as provider within-session behaviours may be the key determinates of parental engagement.

Existing research on both attendance engagement and PPE in child mental health services has documented racial and ethnic differences, with Hispanic families demonstrating lower rates of behavioural (i.e. attendance) engagement in mental health treatment (Miller et al., 2008). Specifically, ethnic minority families are more likely to make slower treatment progress and drop out of treatment compared to non-Hispanic White families (Holden and Lavigne, 1990; Kazdin and Whitley, 2003). Further,Nix et al. (2009) demonstrated that European-American families had better attendance and between-session homework completion, as well as higher within-session participation in a prevention programme for children at high risk for developing conduct problems than Hispanic families. The critical role of engagement in successful treatment suggests that the limited engagement seen among minority families, including Hispanics, may serve as a mechanism further exacerbating the documented disparities in access to and receipt of treatment in this population. While their findings provide some insight into the disparities related to the treatment processes among ethnic minority families, Nix and colleagues did not examine specific ethnic groups and instead grouped all minority backgrounds together. Further, the impact of provider behaviours, including how provider support for parents’ active participation may contribute to ongoing disparities, was not examined. Given the importance of provider behaviours in promoting ongoing therapeutic involvement and compliance, as well as the importance of parent participation in promoting better treatment outcomes (Hoagwood, 2005; Patterson and Forgatch, 1985), a better understanding of the way in which these behaviours may contribute to the broader disparities observed in the receipt and efficacy of health services among Hispanic families compared to non-Hispanic White families is critical.

The presence of differences in in-session participation engagement is supported by some preliminary findings in our prior work examining factors associated with PPE. Specifically, ethnicity was observed to be related to PPE, with Hispanic parents demonstrating significantly lower observed PPE compared to Non-Hispanic parents (Stadnick et al., 2016). However, this work examined a composite of PPE behaviours rather than examining specific PPE ones and did not examine potential ethnic differences in provider use of engagement strategies to encourage PPE. Current literature supports the importance of examining specific components in addition to more broad composites or programmes to enable a more nuanced understanding of parent-mediated interventions (Kaminski et al., 2008). The current study aims to further explore ethnic differences in in-session participation engagement through examining both provider use of engagement strategies to encourage PPE and parents’ specific in-session participation behaviours utilising behavioural observational coding systems. When examining the processes associated with high-quality child services such as PPE, utilising a measure that incorporates in-session behaviours, such as an observational coding system, is often considered the gold-standard given its potential to more directly quantify in-session factors such as behaviour (Shirk and Karver, 2003) and has been shown to be an effective tool for detecting differences in specific in-session provider and parent behaviours (Eames et al., 2010). The use of observational coding to document observed differences in care can provide important information to guide efforts to enhance parent engagement in child mental health treatment.

On the basis of the literature highlighting ethnic differences in treatment utilisation and engagement (Gopalan et al., 2010), we hypothesised that providers would utilise engagement strategies to encourage PPE less extensively with Hispanic/Latino families compared to non-Hispanic/non-Latino families. Similarly, we hypothesised that Hispanic/Latino families would demonstrate lower rates of PPE compared to their non-Hispanic/non-Latino counterparts.

Method

Data from this study were drawn from a randomised pilot study aimed at examining the effectiveness of a free therapeutic toolkit (Parent and Caregiver Active Participation Toolkit, PACT; Haine-Schlagel & Bustos, 2013) to promote PPE in community-based youth mental health services (see Haine-Schlagel, et al. 2016 for a complete description of the study design and methodology).

Participants

Participants included 17 providers and 18 parent-child dyads enroled from five outpatient, community-based mental health clinics in a large Southern California county. With the exception of one provider who was enroled with two dyads, all providers had one parent-child dyad in the study. The provider and parent-child dyad demographics are displayed in Table I.

Table I.

Participant descriptive statistics

Therapist	N = 17; n (%)	Parent-Child dyad	Hispanic/Latino N = 8; n (%)	Non-Hispanic/Non-Latino, N = 10; n (%)
Gender		Parent gender
Male	2 (11.1)	Male	1 (12.5)	1 (10.0)
Female	15 (88.2)	Female	7 (87.5)	9 (90.0)
Mean age (SD)	34.90 (9.3)	Parent mean age (SD)	31.1 (6.28)	39.6 (12.70)
Ethnicity		Race (may have selected > 1)
Hispanic/Latino	11 (61.1)	White/Caucasian	3 (37.5)	6 (60.0)
Non-Hispanic/non-Latino	7 (38.9)	Black/African-American	0 (0.0)	3 (30.0)
Race (may have selected > 1)		Asian	0 (0.0)	1 (10.0)
White/Caucasian	12 (66.7)	Other	8 (100.0)	1 (10.0)
Other	5 (27.8)	Marital status
Primary discipline		Married	4 (50.0)	2 (20.0)
Marriage family therapy	8 (44.4)	Not married/other	4 (50.0)	6 (60.0)
Psychology	4 (22.2)	Highest level of education
Social work	5 (27.8)	Less than high school	1 (12.5)	1 (10.0)
Primary theoretical orientation		High school graduate/GED	4 (50.0)	3 (30.0)
Cognitive behavioural	6 (33.3)	Bachelor’s degree	1 (12.5)	3 (30.0)
Family systems	4 (22.2)	Other	2 (25.0)	3 (30.0)
Eclectic	3 (16.7)	Annual income
Integrative	1 (5.6)	$35,000 or less	7 (87.5)	9 (90.0)
Other	3 (16.7)	$35,001 or more	1 (12.5)	1 (10.0)
Highest degree held		Spoken language (non-English)
Bachelor’s	4 (22.2)	Spanish	7 (87.5)	0 (0.0)
Master’s	12 (66.7)	Other	1 (12.5)	1 (10.0)
Doctorate	1 (5.6)	Child gender
Licensure status		Male	7 (87.5)	8 (80.0)
Licensed	4 (40.0)	Female	1 (12.5)	2 (20.0)
Unlicensed	6 (60.0)	Child mean age (SD)	8.1 (1.64)	9.1 (2.68)
Trainee		Primary diagnosis for child
Trainee	6 (33.3)	ADHD	2 (25.0)	6 (60.0)
Non-trainee	11 (61.1)	Disruptive Behaviours	1 (12.5)	1 (10.0)
Prior training in EBP		Anxiety or mood	2 (25.0)	2 (20.0)
Received prior training	16 (88.9)	Other	2 (37.5)	1 (10.0)
Did not receive prior training	1 (5.6)	Total sessions attendance	84	95
Mean years of experience (SD)	7.17 (9.2)	Mean session attendance	8.4	10.5

Procedures

The providers were recruited through their agencies by research staff. The provider’s eligibility criteria included: agency employment for at least the next five months, providing clinic-based psychotherapy to children and families, and initiating a new episode of care with an eligible parent-child dyad during the recruitment period. The providers were randomised to either use PACT with standard care or standard care alone. Recruited providers approached eligible families regarding consent to be contacted by research staff. Family eligibility criteria included: parent was the child’s legal guardian, parent was English-speaking, parent was at least 18 years of age and child was between 4 and 13 years of age, a presenting issue for treatment was child disruptive behaviour problems (e.g. aggression, noncompliance, delinquency), and parent-child dyad had attended four or fewer sessions with the participating provider. The participants were recruited at the beginning of treatment and followed for four months. Upon enrolment, participants completed a set of baseline surveys, including a demographic survey. They were then asked to complete a monthly survey (up to four), and providers submitted video recordings of therapy sessions with the parent-child dyads to the research team. The participants received honoraria for their participation. Informed consent and child assent for children seven years or older was obtained from all participants by trained research staff. The study received approval by two local Institutional Review Boards.

Measures

Demographics

At baseline, all participants reported on their sociodemographic characteristics, including gender, age, race, ethnicity, and educational history. Parents reported about themselves as well as their participating child[₁]. Providers also reported about their professional background and training (e.g. experience providing mental health services, theoretical orientation). Information regarding the total number of session attended as well as percentage of sessions attended was also collected (see Table I).

PPE Observational Coding System (Haine-Schlagel and Martinez, 2014a). This observational coding system was developed to assess parents’ in-session PPE behaviours, namely the extent to which the parent: shares his/her general perspective, shares his/her perspective about between-session treatment recommendations or home actions, agrees with or appears enthusiastic about home action, asks the provider questions, and demonstrates commitment to therapy. Codes are rated on a five-point Likert scale, with higher scores denoting greater extensiveness of parent participation. The codes were developed to align with an existing observational coding system (Brookman-Frazee and Chlebowski, 2013) as well as a validated measure of PPE, the Parent Participatory Engagement Measure (Haine-Schlagel et al., 2016). Of the 126 full length (approximately 50 minutes) session video recordings received, 93 session recordings were selected for coding to capture behaviours present in the early (i.e. within the first-four sessions), middle (i.e. sessions within the second and third month of treatment), and end (i.e. final session) of treatment. Five undergraduate research assistants participated in training with a Postdoctoral Research Fellow (third author) and a licensed Clinical Psychologist (senior author) until they achieved greater than 80 per cent inter-rater reliability on training recordings. Coders were blind to treatment condition. Session recordings selected for coding included: the initial four sessions after parent/child dyad enrolment, three middle treatment sessions that were approximately one month apart, and the final treatment session. Approximately 30 per cent of sessions were double-coded by a second coder to assess inter-rater reliability. Inter-rater agreement for these double-coded videos was fair to good according to accepted standards (mean interclass correlations (ICC)=0.56; Cicchetti, 1994).

Therapist alliance, collaboration, and empowerment strategies (ACEs) Observational Coding System (Haine-Schlagel and Martinez, 2014b). This observational coding system was developed to assess providers’ in-session use of engagement strategies to encourage PPE, including: alliance (active listening, communicating positive regard), collaboration (offering suggestions, seeking parent input), and empowerment (addressing barriers to participation, recognising parents’ efforts). Codes are rated on a seven-point Likert scale (0–6), with higher scores denoting greater in-session provider strategy use. The codes were developed to align with existing observational coding systems (Brookman-Frazee and Chlebowski, 2013; Garland et al., 2008) as well as the existing literature on parent engagement strategies (e.g. Lindsey et al., 2013). A total of 93 treatment sessions were selected for coding. Selection of recordings and coding training was consistent with the aforementioned process. Approximately 30 per cent were re-coded to assess for inter-coder reliability. Coders were blind to treatment condition. Two codes were dropped due to low agreement/low frequency; the remaining codes exhibited fair to excellent ICCs according to accepted standards (mean ICC=0.63; Cicchetti, 1994).

Data analytic plan

To examine differences in observed provider use of engagement strategies and parent PPE behaviours between Hispanic/Latino and non-Hispanic/non-Latino families, linear mixed model analysis was utilised using the mixed procedure in SPSS 23.0 (SPSS Inc., 2015). This approach was selected given its ability to account for the nested study design (i.e. children nested within providers) and presence of unbalanced data (e.g. non-normality, unequal variances) (Bolker et al., 2008; Raudenbush and Bryk, 2002). Minority status was specified as a fixed effect and entered as a predictor in separate models for each parent in-session PPE and provider use of engagement strategies dependent variables. Given the fact that data were drawn from a randomised pilot intervention study, study condition (PACT vs standard care) was included as a covariate in all analyses.

Results

As shown in Table II, for differences between Hispanic/Latino and non-Hispanic/non-Latino families on parent in-session PPE behaviours, results indicated that Hispanic/Latino parents shared their perspective in sessions less extensively, in particular regarding parent and child between-session home actions as well as generally to some extent. Hispanic/Latino families also appeared less enthusiastic about home actions. Differences in the remaining coded parent in-session behaviours were not observed, including asking questions and demonstrating commitment to therapy, although they were in the same direction. For providers’ use of engagement strategies, results indicated no significant differences in the extensiveness of provider implementation of engagement strategies (i.e. alliance, collaboration, and empowerment) between Hispanic/Latino and non-Hispanic/non-Latino families.

Table II.

Mixed models analyses

			NH vs H N=10 vs 8
Measure/subscale	NH mean (SD)	H mean (SD)	B	SEB	t	ap-value
PPE coding
Share general perspective	3.94 (0.60)	3.46 (0.41)	0.48	0.25	1.93	0.07*
Share home action perspective	3.45 (0.80)	2.65 (0.44)	0.80	0.31	2.55	0.02**
Enthusiasm for home action	3.07 (0.63)	2.15 (0.26)	0.92	0.24	3.85	<0.01**
Asks questions	2.42 (0.51)	2.07 (0.30)	0.35	0.20	1.72	0.10
Commitment to therapy	3.26 (0.63)	2.86 (0.71)	0.40	0.32	1.26	0.23
ACEs coding
Alliance	1.98 (0.79)	2.22 (0.86)	−0.24	0.38	−0.62	0.54
Collaboration	1.25 (0.58)	1.38 (0.34)	−0.14	0.23	−0.58	0.57
Empowerment	2.12 (1.04)	1.71 (1.07)	0.41	0.50	0.82	0.43

Notes: NH, non-Hispanic/Non-Latino; H, Hispanic/Latino; PPE: parent participation engagement; ACES, therapist alliance, collaboration, and empowerment strategies.

^ap < 0.10;

^*p < 0.05;

^**p < 0.01

Discussion

The aims of the current pilot study were to preliminarily examine ethnic differences in in-session provider support for parent participation and parent’s actual participation in their child’s mental health treatment. Our results suggested differences in parents’ in-session PPE behaviours, such that Hispanic/Latino families shared less of their general perspective as well as their perspective regarding parent-child home actions with providers. However, differences were not observed in provider strategy use.

In terms of parents’ in-session PPE behaviours, our preliminary findings regarding ethnic discrepancies in parents’ input into planning for home actions expand prior work demonstrating disparities in homework completion (Nix et al., 2009) by providing possible insight into contributing factors behind this non-completion. In particular, it is possible that families’ limited homework completion observed by Nix and colleagues is partially due to their limited input into home actions or homework. The lack of differences in the asking questions and demonstrating commitment to therapy codes is of interest, in particular given data suggesting that Hispanic/Latino families refrain from asking questions and instead defer to their providers regarding health care decisions (Levinson et al., 2005; Rooks et al., 2012). Further, the key cultural values would suggest that Hispanic/Latino families pose fewer questions compared to non-Hispanic/non-Latino ones. For example, the cultural value of respeto, which values obedience or deference to authority, plays a key role in child rearing and is thought to have direct implications for the efficacy of evidence-based parenting programmes for certain Latino subgroups (Calzada et al., 2010). Therefore, the similar number of questions observed across families is surprising and in contrast to previous findings. It is important to note the possibility that, given the same direction observed for all estimates of specific parent in-session behaviours, nonsignificant findings observed for asking questions and commitment to therapy may be an issue of statistical power vs true similarities between families. However, the small, pilot nature of these data preclude us from further examination, including exploring factors contributing to this finding, including culture and cultural values, and further work examining the impact of such factors is warranted.

Importantly, this is one of the first studies to utilise a direct measure of engagement of in-session participatory behaviours, and our results are consistent with the current nascent data support the use of a more nuanced approach to examining provider and parent in-session behaviours (Eames et al., 2010). Despite the small sample size, significant differences were still observed for two participation behaviours, suggesting that in-session behaviours may be an important measure of treatment engagement that complements and expands ethnic disparities studies that utilised broader attendance measures of engagement (e.g. drop-out, attendance; Miller et al., 2008; Nix et al., 2009).

In terms of provider engagement strategy use, further examination of the study’s measure of provider strategies may help explain these null findings. Specifically, there was limited variability in our ACEs coding measure (see Table II), indicating that providers utilised engagement strategies with only low to moderate extensiveness. This is not surprising given data suggesting that providers do not involve parents to a great extent in care (Haine-Schlagel et al., 2012) and often deploy strategies with sufficient intensity than would be expected from evidenced-based treatment models (Garland et al., 2010). It is important to note that the lack of provider engagement behaviour differences in this preliminary study are consistent with an observational study of differences in providers’ delivery of an evidence-based mental health intervention for children with autism spectrum disorder, which found no disparities between Hispanic/Latino families and non-Hispanic/non-Latino ones in providers overall caregiver engagement efforts (Wright et al., 2015). Overall, the current pilot study’s results are encouraging given differences in the care provided were not demonstrated; however, it is important to note that the current study only examined a limited number of provider’s in-session engagement behaviours. As such, efforts to examine additional provider in-session behaviours are warranted.

Our current exploratory results also suggest the need for greater attention to examining and developing interventions to address ethnic differences in the degree to which parents participate actively in child mental health treatment sessions. In particular, our results suggest a need to better understand the factors limiting Hispanic families’ willingness to share their perspective as well as their enthusiasm for home actions. This includes an examination of other unexamined factors (e.g. stigma, mental health literacy) beyond in-session engagement behaviours that may be impacting the potential disparities in mental health care within this population. As the Mental Health Services Ecological model suggests (Rodriguez et al., 2014), larger observational studies are needed to identify potential family, provider, and organisational factors that may impact ethnic differences in parent participation to build and implement interventions that promote active parent participation across all families.

Finally, our results also speak to the distinction between health equality and health equity made in the literature, with the former referring to equal allocation and receipt of services and the latter referring to the distribution of resources that systematically contribute to a health equality (Braveman and Gruskin, 2003; Culyer and Wagstaff, 1993). That is, whereas health equity is fundamental to health quality, these constructs are not necessarily synonymous. Specifically, our results suggest that while providers appeared to treat all families “equally”, suggesting health equality, Hispanic/Latino families exhibited lower levels of participatory behaviours, suggesting health inequity. Providers may need to forgo equal treatment and instead adjust their own behaviours in order to enhance parent participation among Hispanic/Latino families, thereby promoting more equitable health outcomes as a result. Again, further research examining differences in parent participation behaviours is needed, especially as it relates to provider’s cultural understanding and the need to provide additional in-session supports to enhance equity if care for Hispanic/Latino families.

Several limitations to the present study should be noted. First, the pilot nature of the current study resulted in a small sample size, thereby limiting statistical power and the generalisability of the current findings. Our small sample size also limited our ability to adjust for other social determinants such as socioeconomic status and parental education; however, our preliminary analyses did not indicate any significant demographic differences across our two groups, suggesting that these variables were not likely having a significantly impacting our results. Our small sample size also precluded further exploration of potential differences within our sample, including examining differences across Hispanic subgroups (e.g. Mexican, Puerto-Rican) or racial background. While falling within the acceptable range, the variability in our ICCs of our observational coding systems warrant caution in the interpretation of these results. Yet, the current findings provide a glimpse into the nature of children services and the factors that may impact disparities in how families respond to treatment that are worthy of further investigation.

Further, our observational coding system cataloguing in-session behaviour contributes to the budding literature supporting the utility of more direct measures of in-session engagement and behaviours. Future, well-powered, studies further examining in-session provider and parent engagement behaviours are warranted. Moreover, we assessed a limited set of constructs in the current pilot study. Future studies should further examine constructs known to impact PPE, such as parent and provider perspectives on rapport, to better understand the role it plays in observed disparities in parent participation. Finally, the current results may also be attenuated by including only English-speaking families in the sample. Given the role of language as a significant barrier to treatment (Sentell et al., 2007), it is possible that further disparities would be observed among Spanish-speaking families. This should be explored further using larger samples that include Spanish-speaking families.

Conclusions

This study’s results demonstrated utility in observational coding as a method for assessing disparities in parent participation and provider engagement behaviours in community-based child psychotherapy. Specifically, we were able to show differences across dimensions of engagement beyond treatment attendance among Hispanic/Latino parents when compared to their non-Hispanic/non-Latino counterparts. Our results suggest that the use of observational coding in future studies assessing PPE in larger samples and targeting PPE in intervention settings is warranted.

Implications for policy and practice.

• ▪The current study demonstrated the utility of an in-session observational coding system as a measure of treatment engagement, supporting its value in informing future policy and practice efforts targeting parent engagement.

Biographies

Kelsey S. Dickson, PhD is a Postdoctoral Scholar in the Department of Psychiatry and the Child and Adolescent Services Research Center (CASRC) and a licensed Clinical Psychologist. Dr Dickson’s current work concentrates on services research aimed at the adaptation and implementation of evidenced-based interventions (EBIs) for youth in community-based service settings. Dr Dickson is additionally interested in applying an implementation science framework to improve the adoption of EBIs in community services through incorporation of underlying mechanisms of symptomatology (i.e., Executive Functioning).

Sasha M. Zeedyk, PhD, is an Assistant Professor of Child and Adolescent Studies at California State University, Fullerton. Dr Zeedyk’s research focuses on the social and behavior skills of youth with autism spectrum disorders and intellectual disabilities across the course of development. She is interested in understanding how behavior problems and social skills relate to social, mental health, and academic outcomes for these youth, as well as how these skills impact their parents’ psychological well-being.

Jonathan Martinez, PhD has demonstrated a long-standing commitment to children's mental health services research and improving the quality and outcomes of care for culturally diverse children and families. His program of research addresses this central question: How can we bridge the science-to-practice gap by implementing evidence-based, culturally-responsive practices in community mental health settings to reduce disparities in care for ethnic minority families? Dr Martinez is currently an Assistant Professor at California State University, Northridge, where he has developed my PUENTE (promoting the use of evidence-based practices: narrowing the treatment engagement gap) research lab to address this science-to-practice gap.

Dr Rachel Haine-Schlagel is currently an Assistant Professor in the Department of Child and Family Development at San Diego State University. She is also an Investigator at the Child and Adolescent Services Research Center, as well as a licensed Psychologist and certified Trainer for an evidence-based engagement intervention for child and family mental health services. Her research focuses on understanding and promoting family participation in community-based services for children and families.