Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Feb 20.
Published in final edited form as: J Clin Child Adolesc Psychol. 2020 Aug 20;51(2):230–241. doi: 10.1080/15374416.2020.1796682

Impact of Therapist Training on Parent Attendance in Mental Health Services for Children with ASD

Kelsey S Dickson a,b, Colby Chlebowski b,c, Rachel Haine-Schlagel a,b, Bill Ganger b,d, Lauren Brookman-Frazee b,c,e
PMCID: PMC7987108  NIHMSID: NIHMS1671144  PMID: 32816564

Abstract

Objective:

The current study explored the impact of training therapists in a mental health intervention for children with autism spectrum disorder (ASD) on parent attendance in their children’s therapy sessions. We also examined family, therapist, and program factors as potential moderators.

Method:

Data were drawn from a cluster-randomized community effectiveness trial of “An Individualized Mental Health Intervention for ASD (AIM HI)”. Participants included 168 therapists yoked with 189 children recruited from publicly-funded mental health services. Data included family (caregiver strain, parent sense of competence, race/ethnicity), therapist (background, experience), and program (service setting) characteristics, and parent session attendance. Multilevel models were used to evaluate the effectiveness of AIM HI therapist training on caregiver attendance and identify moderators of training effects on parent attendance.

Results:

Parents attended a higher percentage of sessions in the AIM HI training condition compared to the Usual Care condition. Program service setting moderated the effect of AIM HI training, with higher parent attendance in non-school (mostly outpatient) settings compared to school settings and a significantly smaller difference between the settings in the AIM HI condition.

Conclusions:

Effective strategies to promote parent engagement, especially in-service settings such as schools, are warranted. Findings support the effectiveness of AIM HI training in promoting parent attendance across multiple publicly-funded mental health service settings. The larger effect in school-based programs supports the utility of training in evidence-based interventions such as AIM HI to increase the feasibility of parent attendance in such services.

Parent and caregiver (hereafter referred to as parent) engagement is widely documented as an important component of and a key quality indicator in children’s mental health services (Becker et al., 2018; Gopalan et al., 2010; Haine-Schlagel & Walsh, 2015; Wright et al., 2019). Attitudinal engagement refers to cognitive dimensions such as attitudes about or expectations of treatment, whereas behavioral engagement encompasses observable behaviors indicative of active treatment participation such as utilization, attendance, homework completion, or in session participation (Haine-Schlagel & Walsh, 2015). Behavioral parent engagement is particularly critical for many evidence-based interventions (EBIs) for children that require a large parental role and explicitly target development of parent skills (Evans et al., 2018; Higa-McMillan et al., 2016; McCart & Sheidow, 2016). Parent behavioral engagement has been shown to contribute to improved outcomes, including key child (e.g., improved functioning or symptom reduction), family (e.g., reduced parental stress, increased parental selfefficacy) and services (e.g., lower premature treatment dropout) outcomes (Burrell & Borrego, 2012; Dowell & Ogles, 2010; Haine-Schlagel & Walsh, 2015). The most commonly reported indicator of behavioral engagement is parent attendance in children’s sessions (Barnett et al., 2019; Kaminski & Claussen, 2017; Sun et al., 2019; Wright et al., 2019).

Factors Associated with Parent Behavioral Engagement in Publicly-Funded Mental Health Services

Publicly-funded mental health services play an important role in caring for children with mental health problems, with Medicaid serving as the single largest payer of mental health care in the United States (Mark et al., 2005). Research conducted in these settings documents multilevel factors associated with parent behavioral engagement, including family, therapist, and variables among others (Barnett et al., 2019; Wright et al., 2019).

Family Factors and Parent Behavioral Engagement.

There is a relatively large body of literature examining the role of several parent and family factors in parent behavioral engagement. Caregiver strain or stress is consistently linked with child outpatient and school-based mental health services utilization (Brannan et al., 2003; Burnett- Zeigler & Lyons, 2010). Furthermore, parents’ self-efficacy or competency is positively associated with engagement (Brannan et al., 2003; Burnett-Zeigler & Lyons, 2010; Haine-Schlagel & Walsh, 2015; Pereira & Barros, 2019). Recent work also documents racial and/or ethnic differences in engagement, with lower engagement in community mental health services observed among Latinx parents (Dickson et al., 2017; Guan et al., 2019; Haine-Schlagel & Walsh, 2015). Examination of behavioral engagement may be especially critical among parents of children with autism spectrum disorder (ASD), for whom higher rates of caregiver strain as well as service challenges and disparities are common (Falk et al., 2014; Hayes & Watson, 2013; Mandell et al., 2009).

Therapist Factors and Parent Behavioral Engagement.

There is a small but growing body of literature examining the associations between therapist factors and indicators of parent behavioral engagement. In publicly-funded outpatient children’s mental health services, therapists were observed to direct EBI strategies toward parents in less than half of sessions, with more experienced therapists directing more strategies to parents in sessions (Haine-Schlagel et al., 2012). Additionally, therapists’ use of EBI strategies that prescribe parent attendance at all sessions was associated with higher attendance (Garland et al., 2012; Wright et al., 2019). Therapists who received formal training in parent-mediated interventions and those with higher ratings of self-efficacy were observed to have higher in-session parent participation engagement (Stadnick et al., 2016). These findings highlight the key link between therapist experience and training in promoting parent behavioral engagement in their child’s mental health services, which may be especially critical for populations that pose significant service challenges such as children with ASD.

Role of Service Setting in Parent Behavioral Engagement.

Although much of the engagement research has been conducted within the context of outpatient mental health services, many child mental health services are provided in schools. School-based mental health programs may be the “de facto” provider of mental health services for children who might not otherwise have access to care (Pullmann et al., 2010; Whitaker et al., 2018). Further, federal and state education laws in the United States place the responsibility for mental health care on the education system when children’s mental health conditions are interfering with their educational functioning (U.S. Department of Education, 2004; State of California Assembly Bill 114, 2011).

Whereas school-based settings may reduce barriers to care for children, additional barriers for parent engagement in these settings may exist (Atkins et al., 2010). Recent findings indicate that school-based therapists are significantly less likely to involve parents either through phone or in-person interactions than non-school-based providers (Woodard et al., 2019), despite parents’ desire to be more involved in their child’s school-based services (George et al., 2014). This may be in part due to perceived challenges engaging parents, as school-based therapists report significant barriers engaging parents, and have limited experience and support in involving families that may be related to differing backgrounds and professional training among school-based providers compared to other providers (Fazel et al., 2014; George et al., 2014; Langley et al., 2010). As limited parent engagement is a key barrier to implementation of behavioral EBIs in school settings (Gopalan et al., 2008; Langley et al., 2010), further efforts to strengthen parent involvement in school-based mental health services are needed.

Gaps in the Current Literature Examining Factors Impacting Parent Behavioral Engagement.

There is increased attention to parent behavioral engagement within the context of community EBI implementation (Barnett et al., 2019; Wright et al., 2019); however, information on the effectiveness of EBI training on parent engagement in publicly-funded mental health services specifically is limited. Furthermore, it is not known how factors previously identified as associated with parent engagement may moderate the impact of EBI therapist training efforts.

Examining Parent Engagement in Publicly-Funded Mental Health Services for Autism Spectrum Disorder

Parent participation in services is particularly important for children with ASD (Brookman-Frazee, Chlebowski, Villodas, & Martinez, 2020; Brookman- Frazee, Vismara et al., 2009; Burrell & Borrego, 2012). The primary goals of parent participation in ASD interventions are to increase the intensity of services by teaching parents to facilitate child skill-building in the child’s natural environment and help promote generalization of skills learned within the context of the intervention to other settings, a particular challenge for children with ASD (Brookman-Frazee, Vismara et al., 2009).

Publicly-funded mental health settings play an important role in caring for children with ASD, including their co-occurring psychiatric conditions (Brookman-Frazee, Baker-Ericzén et al., 2009; Brookman-Frazee et al., 2012). Unfortunately, mental health therapists report limited ASD training, urgently requesting tools to support their practice with this population (Brookman-Frazee et al. 2010, 2012).Further, there is a lack of research on parent behaviora engagement in mental health services for the ASD population. The majority of the extant literature focuses on engagement in children’s mental health services broadly versus a specific focus on services for children with ASD (e.g., Becker et al., 2018; Haine- Schlagel & Walsh, 2015). In contrast, the existing literature examining parent involvement in ASD interventions (e.g., Burrell & Borrego, 2012; Pellecchia et al., 2018) have primarily been conducted within research (vs usual care) settings.

Thus, a better understanding of parent behavioral engagement in mental health services for children with ASD is needed, including moderators of the impact of training community mental health therapists to deliver a parent-mediated intervention on parent engagement. This is especially important given data suggesting that key barriers to parent engagement (e.g., high rates of stress, lower parenting self-efficacy or competence) are common in parents of children with ASD, especially in response to child challenging behaviors (Falk et al., 2014; Hayes & Watson, 2013). The current study offers the opportunity to address this knowledge gap by examining parent behavioral engagement in children’s mental health services within the context of training therapists in an intervention model developed specifically for delivery in publicly-funded mental health services for ASD.

An Individualized Mental Health Intervention for ASD (AIM HI)

In response to the need for a scalable intervention protocol and therapist training model, AIM HI (“An Individualized Mental Health Intervention for ASD”; Brookman-Frazee & Drahota, 2010; Brookman-Frazee et al., 2016) was developed for use in publicly-funded mental health settings for children with ASD. AIM HI addresses challenging behaviors, the most common presenting problem for children with ASD served in these settings (Brookman-Frazee et al., 2012). AIM HI is a package of evidence-based parent-mediated and child-focused behavioral intervention strategies designed to reduce challenging behaviors in children with ASD aged 5 to 13 years. In an initial pilot feasibility study, therapists reported an increased level of parental involvement and collaboration in services following 6 months of AIM HI training/consultation, in addition to improvements in child behaviors (Drahota et al., 2014). Therapists also reported the ability to implement AIM HI effectively even in the presence of parental stress or parental characteristics, such as mental health problems or cognitive limitations (Drahota et al., 2014). Similarly, parents indicated increased levels of involvement in services and collaboration with their child’s therapist when the therapist delivered AIM HI (Stadnick et al., 2013). These early pilot data suggest that therapist training/consultation in AIM HI resulted in changes in the amount and type of parent behavioral engagement compared to usual care mental health services.

Results from a subsequent cluster randomized controlled community effectiveness trial indicate that children whose therapists participated in AIM HI training/ consultation showed significantly greater improvements in challenging behaviors compared to children whose therapists did not receive AIM HI training and delivered usual care (Brookman-Frazee et al., 2019). A significant training effect was also observed for parental sense of competence, with parents whose child’s therapist received AIM HI training reporting greaterimprovements in feelings of parental competence compared to parents whose children were receiving care as usual (Brookman-Frazee, Chlebowski, et al., 2020). Recent findings using observational data to characterize in-session parent behaviors during the early phases of AIM HI also support the importance of examining family factors associated with parent engagement, with lower engagement observed among Latinx parents (Guan et al., 2019). Taken together, these findings point to the importance of considering multilevel family and therapist factors when examining the impact of therapist training in AIM HI on parent attendance.

Study Aims

The goals of the current study are to examine the following within the cluster-randomized community effectiveness trial of AIM HI: (1) the effectiveness of training therapists in AIM HI on parent attendance and (2) family, therapist, and program factors as moderators of training effects on parent attendance.

Methods

Study Context

Data for the current study are drawn from a cluster randomized community effectiveness trial. A detailed description and trial protocol is provided in (Brookman-Frazee et al., 2019). Briefly, publicly-funded outpatient and school-based mental health programs were enrolled and randomized to immediate AIM HI training/consultation or a wait-list control observation/delayed training condition. Once programs were enrolled and randomized to training conditions, therapists from participating programs were recruited and enrolled as a “dyad” with an eligible client drawn from on their existing caseload. The training and observation period lasted 6 months; during that time therapists in the training condition received initial training and ongoing consultation while they delivered AIM HI to their participating child/family. Therapists in the observation condition were observed while they delivered usual care to a participating child/family. All therapists submitted video recordings of their therapy sessions during the 6 month training/observation study period.

AIM HI intervention and training protocol.

The AIM HI intervention (Brookman-Frazee & Drahota, 2010; Brookman-Frazee et al., 2016) is designed to reduce challenging behaviors in children with ASD by teaching children positive alternative skills and teaching parents antecedent and consequence-based strategies to promote their child’s use of skills. AIM HI is a package of evidence-based strategies considered “well established” for ASD (National Autism Center, 2015; Wong et al., 2015). Therapists are trained to collaborate with parents to identify the primary functions of a child’s challenging behaviors, identify child alternative skills and complementary parent skills, and actively teach both child and parent skills in session. Skills are taught to children and parents using “active teaching” strategies, including therapist modeling of skills, behavioral rehearsal accompanied by targeted feedback and reinforcement, and assignment and review of between-session practice (e.g., homework). AIM HI also includes strategies to adapt psychotherapy structure for an ASD population to facilitate engagement and skill building (e.g., using visuals and schedules to maximize predictability). For information about the intervention protocol see Brookman-Frazee et al., 2020.

Therapist training occurred over the six month study period while therapists implemented AIM HI with their client. Therapists participated in an initial training workshop followed by 11 consultation meetings (9 group, 2 individual) with an expert AIM HI trainer who provided both dydactic instruction and case-specific feedback. An intervention manual and a resource website offering video exemplars and electronic copies of intervention materials was provided for therapist self-study. Over the training period, performance feedback on therapist delivery of AIM HI was provided based on trainer review of video recordings of therapy sessions.

Participants

Participants in the AIM HI effectiveness trial included 202 children and 172 therapists (Brookman-Frazee et al., 2019). Therapists employed as trainee or staff at a participating program with a child on their caseload meeting the client inclusion criteria were eligible for study participation. Children and caregivers were recruited from the existing caseloads of participating therapists. Child inclusion criteria included children aged 5–13 years at the time of study enrollment presenting for mental health services with a challenging behavior. Children were required to have an existing diagnosis of ASD and/or clinically significant ASD symptoms on at least one of two standardized ASD diagnostic measures: the Autism Diagnostic Observation Schedule-2 (ADOS-2; Lord et al., 2012) or the Social Responsiveness Scale-2 (Constantino & Gruber, 2012). Parents were eligible if they were the parent of a child meeting study eligibility criteria. Of the child and therapist participants in the trial, a subset of 189 children and 168 therapists with data on session attendance were included in the current study. Participant characteristics are provided in Table 1.

Table 1.

Program and participant characteristics

Usual Care AIM HI Total
Program n=14 n=12 n=26
 Youth with primary school-based session location 54.5% 60.7% 32.3%
 Youth with non-school primary session location 21.4% 74.5% 67.7%
Therapist characteristics n=41 n=127 n=168
 Therapist age (years) M(SD) 34.85 (7.81) 33.90 (8.32) 34.13 (8.18)
 Therapist gender (female) 87.8% 85.8% 86.3%
 Therapist race/ethnicity
  Hispanic/Latinx 41.5% 32.3% 34.5%
  Non-Hispanic White 56.1% 46.5% 48.8%
  Asian/Pacific Islander 2.4% 13.4% 10.7%
  African American 0.0% 3.1% 2.4%
  Multiracial 0.0% 0.8% 0.6%
  Unknown/Not Reported 7.3% 3.9% 3.0%
 Primary mental health discipline (%)
  Marriage and Family Therapy 48.8% 42.5% 44.0%
  Psychology 14.6% 23.6% 21.4%
  School Psychology 0.0% 1.6% 1.2%
  Social Work 24.4% 26.8% 26.2%
  Other Discipline[1] 12.2% 4.7% 6.6%
 Licensed in mental health discipline (%) 26.8% 28.3% 28.0%
Parent/family characteristics n=44 n=145 n=189
 Child age (years) M(SD) 9.36 (2.39) 9.08 (2.48) 9.15 (2.46)
 Child gender (male) 84.1% 84.1% 84.1%
 Parent age (years) M(SD) 38.49 (3.91) 40.77 (8.69) 40.24 (8.35)
 Parent gender (female) 97.7% 92.4% 93.1%
 Parent race/ethnicity
  Hispanic/Latinx 54.5% 50.3% 51.3%
  Non-Hispanic White 29.5% 35.9% 34.4%
  Asian/Pacific Islander 0.0% 6.9% 5.3%
  African American 9.1% 3.4% 4.8%
  American Indian/Alaskan Native 2.3% 0.7% 1.1%
  Multiracial 4.5% 2.1% 2.6%
 Parent marital status (married) 40.9% 55.2% 51.9%
 Maternal education level
   Less than high school 13.6% 20.7% 19.0%
   Completed high school 50.0% 33.1% 37.0%
   Any trade school/college 34.1% 45.5% 42.9%
 Annual household income
  ≤$25,000 56.8% 42.1% 45.5%
  $25,001–75,000 2935% 40.0% 37.6%
  >$75,000 13.6% 17.9% 16.9%
Open in a new tab
[1]

Other Discipline includes Psychiatry, Licensed Professional Clinical Counselor, Art Therapist

Measures

Covariates

Child Demographics.

Baseline eligibility assessments were conducted by the research team for all referred children, including collection of child demographics.

Outcome Measure

Therapist Report of Parent Attendance.

Parent attendance was measured based on therapist monthly report of the number of sessions and participants present in session collected monthly over the six-month training or observation period. Therapists reported the date and length of each session that occurred in the previous month, the location of the session, and who was involved in the session (client, caregiver, school staff, other). The percentage of all sessions (child only, child and parent, parent only) with parent attendance over the 6-month study period was then calculated.

Moderator Variables

Family characteristics.

As part of baseline eligibility assessments, family demographic characteristics were collected, including parental race and ethnicity, marital status and education level. Parents also completed a rating scale measuring caregiver strain (Caregiver Strain Questionnaire [CGSQ]; Brannan, Heflinger, & Bickman, 1997) and parental feelings of competence (Parenting Sense of Competence [PSOC]; Johnston & Mash, 1989). For the current study, continuous measures of caregiver strain, parental feelings of competence, and a categorical variable representing caregiver race/ethnicity (Non-Hispanic/Latinx White, Hispanic/Latinx, and other) were included in analyses.

Therapist characteristics.

At study baseline, therapists completed an online survey that included information about their clinical background and experience. For the current study, therapist licensure status and previous training in parent-mediated interventions were included.

Program Service Setting.

A categorical variable representing the primary setting (school versus non-school setting) in which psychotherapy/counseling services were provided was utilized. Specifically, therapists reported the location of each therapy session in the monthly session reports. The percentage of sessions conducted in schools and other settings (e.g., outpatient clinic, home) were calculated. Children who had greater than 50% of sessions in schools were considered to have schools as their “primary” service setting.

Analytic Plan

For the first aim examining the impact of AIM HI therapist training on the proportion of sessions attended by parents, a multilevel regression model was used to account for the clustered nature of the data (i.e. therapist-client dyads [level 1] nested within enrolled mental health programs [level 2]). Child gender and age were included as covariates in all models. For the second aim, moderators (e.g., family, therapist, and program characteristics) of training group differences were evaluated by adding interaction terms for variables with significant main effects to the multilevel models. Preliminary analyses were conducted to examine the associations between moderator variables. All analyses were conducted in Stata 15.0 (StataCorp, 2017).

Results

Aim 1: Impact of Therapist Training on Parent Attendance

Analyses examining the effectiveness of therapist training in AIM HI on parent attendance indicated a significant impact of training condition, with AIM HI parents attending a higher percentage of their child’s sessions (EMMAIM HI =73.44, SE =4.95) compared to UC parents (EMMUC = 42.62, SE = 5.60), Estimate = 30.82, p<.001 (see Table 2 for full results).

Table 2.

Multilevel models examining family, provider, and settings factors as moderators of therapist training on parent attendance

Predictor Main Effects Models Main Effects and Interactive Effects Model
B (SE) z p B (SE) z p
Aim 1
 Training Conditiona 31.73 (5.13) 6.19 <.001 -- --
 Child Gender 3.58 (4.41) .81 .42 -- --
 Child Age −1.34 (.72) −1.85 .06 -- --
Aim 2- Family Factors
 Conditiona 31.27 (4.95) 6.32 <.001 -- --
 PSOC −.03 (.17) .87 .87 -- --
 CGSQ 3.02 (2.17) 1.39 .17 -- --
 Caregiver Ethnicityb- Hispanic −.07 (3.66) −.02 .98 -- --
 Caregiver Ethnicityb- Other −7.22 (5.02) −1.44 .15 -- --
 Child Gender .87 (4.26) .20 .42 -- --
 Child Age −1.08 (.69) −1.55 .07 -- --
Aim 2 Provider Factors
 Training Conditiona 31.66 (5.13) 6.17 <.001 -- --
 Licensure Status 1.09 (4.26) .26 .80 -- --
 Prior Training 1.90 (4.68) .41 .69 -- --
 Child Gender 3.59 (4.45) .81 .42 -- --
 Child Age −1.31 (.72) .72 .07 -- --
Aim 2 Setting Factors
 Training Conditiona 28.24 (4.27) 6.61 <.001 41.77 (5.92) 7.06 <.001
 Settingc 37.68 (4.22) 8.94 <.001 53.59 (6.80) 7.88 <.001
 Child Gender 2.57 (4.07) .63 .53 2.77 (3.93) .71 .48
 Child Age −1.56 (.63) −2.44 .01 −1.37 (.63) −2.19 .03
 Condition X Setting -- -- −25.78 (7.84) −3.29** .001
Open in a new tab

Notes.

a

Condition was coded as 0 = Usual Care, 1 = AIM HI;

b

Non-Hispanic/Latinx White is the reference group

c

Primary session location was coded as 0 = School, 1 = Non-School Based. PSOC = Parenting Sense of Competence. CGSQ = Caregiver Strain Questionnaire

Aim 2. Examining Family, Therapist, and Program Factors as Moderators on Therapist Training on Parent Attendance

Preliminary analyses assessing associations between moderator variables revealed a significant correlation between caregiver strain and parent sense of competence (r=.43, p<.001). However, examination of tolerance (all <.2) and variance inflation factors (all <1.5) were below recommended cutoffs, indicating limited concerns regarding multicollinearity (Hair, Black, Babin, Anderson, & Tatham, 2006). Furthermore, there were no significant differences between setting and other moderator variables. Family (caregiver strain, parental sense of competence, race/ethnicity) and therapist factors (licensure status and previous training) did not moderate the effect of AIM HI training on parent attendance. There was a significant interaction between training condition and setting (Estimate=−25.78, Wald X2(5)= 156.99, p<.001). Simple effects analyses indicated that in both conditions, higher parent attendance was observed in non-school settings compared to school settings (p’s<.01); however, for the AIM HI condition, the difference between school (EMMSchool = 57.95, SE = 4.50) and non-school settings (EMMOther = 85.76, SE = 3.47) was significantly smaller compared to usual care (EMMSchool = 16.18, SE = 4.90; EMMOther = 69.77, SE = 5.36), p<.001. Parent attendance in schools in the AIM HI condition approximated that seen in non-school settings (e.g., clinics, home) among the usual care condition (see Figure 1). See Table 2 for full results.

Figure 1.

Figure 1.

Open in a new tab

Percent parent attendance.

Discussion

The current study examined the effectiveness of training therapists to deliver a parent-focused intervention for children with ASD on parent attendance at their child’s mental health sessions. Results support the effectiveness of AIM HI in promoting parent attendance, with parents working with therapists trained in AIM HI attending a higher percentage of their child’s sessions. Service setting moderated the training effects such that there was higher attendance in non-school settings (primarily outpatient clinic) as compared to school settings. However, the difference between schools and non-school settings was significantly smaller in the AIM HI condition, with the rates of parent attendance for families in the AIM HI condition served in school settings approximating that seen in non-school based settings in usual care.

The current findings add to the growing literature supporting the effectiveness of training therapists in AIM HI in improving key child (symptoms, functioning) and parent (parent sense of competence/self-efficacy) outcomes (Brookman-Frazee, Roesch, et al., 2019; Brookman-Frazee et al, 2020). Specifically, results suggest that training therapists to deliver AIM HI may be effective in increasing parent participation in mental health services for children with ASD served in school settings, which may further contribute to improved child outcomes (Brookman-Frazee, Vismara, et al., 2009; Burrell & Borrego, 2012; Dowell & Ogles, 2010). Findings also underscore the value of providing therapist training in EBIs targeting caregiver skills to improve key parent engagement behaviors identified in the broader children’s mental health literature (Garland et al., 2012; Stadnick et al., 2016). There are growing efforts to develop and test strategies to facilitate parent engagement for the broad population of children receiving publicly-funded mental health services (e.g., Becker et al., 2015; Haine-Schlagel, Martinez, Roesch, Bustos, & Janicki, 2018). Parents of children with ASD may experience particularly high levels of strain and competing demands that can make engagement in their child’s treatment challenging (Cohrs & Leslie, 2017; Gopalan et al., 2010; Khanna et al., 2011). Engaging parents of children with ASD has also been identified as particularly challenging by mental health therapists who do not specialize in the needs of this population (Brookman-Frazee et al., 2012). Additionally, parent-mediated EBIs targeting co-occurring mental health conditions in ASD are increasingly being used with this population (Postorino et al., 2017; Vetter, 2018). As such, the need to further efforts specifically targeting engagement among parents of children with ASD within mental health services is important (Pellecchia et al., 2018; Stahmer & Pellecchia, 2015).

Service setting moderated the effect of AIM HI training, with a larger effect of AIM HI training observed for school-based providers on parent attendance. This finding suggests that appropriate training, such as that offered as part of AIM HI, can improve the feasibility of parent attendance, even in school-based settings where parent participation is less common, challenging, and often a barrier to the delivery of EBIs (George et al., 2014; Langley et al., 2010; Woodard et al., 2019). These findings are particularly meaningful given that schools provide as much as 80% of mental health services delivered to children (Burns et al., 2003; Farmer, Burns, Phillips, Angold, & Costello, 2003). Parent participation in school-based mental health services contributes to improved outcomes across multiple domains and parents report motivation to be involved in their child’s school-based services (George et al., 2014; Mendez, Ogg, Loker, & Fefer, 2013). Yet as is noted, school-based providers report challenges to engaging parents and cite a need for additional training and supports engaging caregivers (Fazel et al., 2014; George et al., 2014; Langley et al., 2010). Results suggest that AIM HI training may be an effective way to address school-based providers’ need for additional supports in engaging parents in their child’s services.

In contrast to service setting, family and therapist factors did not significantly moderate the effects of training on parent attendance. These findings differ from prior research identifying both family and provider factors as important determinants of therapist EBI and parent engagement strategy delivery in routine care (Garland et al., 2012; Haine-Schlagel & Walsh, 2015; Stadnick et al., 2016; Wright et al., 2019). Interestingly, the current results also differ from Guan and colleagues (2019) finding demonstrating significantly lower initial engagement among Latinx caregivers receiving AIM HI. These discrepant findings may be due to differences in samples, with Guan et al., examining a subsample of 39 caregivers during the first two months of services within the AIM HI condition only versus the current analyses including the full sample of trial participants in both AIM HI and Usual Care condition over six months. Further, the current work relied on parent attendance as the primary measure of engagement versus in-session parent behaviors (e.g., asking questions and participating in session activities), which also may account for the differing findings. Taken together, these findings suggest that further research examining the nature and impact of multilevel determinants on parent engagement, especially those incorporating various (e.g., observational, objective) measures of various components of engagement, are needed.

The current findings also suggest that program-level factors such as service settings may have an especially important impact on parent attendance. School-based settings have different organizational structures or supports that are known to hinder providers’ EBI adoption and implementation (Dyson, Chlebowski, & Brookman-Frazee, 2018; Langley et al., 2010). Despite these potential barriers, school-based therapists trained in AIM HI facilitated more parent attendance than usual care school providers without the implementation of structural changes at an organizational level, suggesting that providers who receive appropriate training in strategies to engage parents may be able to successfully do so despite larger structural challenges. This notion is consistent with work by Langley and colleagues (2010) examining determinants to successful and unsuccessful EBI implementation among school-based mental health providers. Specifically, they demonstrated that similar barriers were experienced by both groups, including those related to organizational structure or support, but successful implementers were able to overcome these barriers via availability of key implementation supports such as ongoing intervention-specific consultation or networking. Specific to parent attendance, Israel and colleagues (2007) found that between-setting variations accounted for significant variance in attendance despite large similarities in organizational structure, further supporting the importance of non-structural characteristics in promoting parent engagement. Thus, interventions and trainings specifically addressing parent engagement, such as AIM HI, may be useful to supporting school-based providers’ ability to overcome barriers in EBI delivery.

The current study has several strengths. Examining the effectiveness on training therapists in a package of EBI strategies on parent attendance for the high priority population of children with ASD served in mental health settings is important. Similarly, the examination of the moderating effects of service settings contributes to the limited literature examining parental attendance and participation within the context of school-based mental health services. However, these findings should be considered within the context of study limitations. First, there is an uneven number of participants by service setting between AIM HI and Usual Care conditions. A cluster randomized trial design was employed where programs were randomized and therapist and child/family participants were recruited from within enrolled programs. Program randomization was not stratified by setting. Second, parent attendance is just one indicator of parent engagement. We recognize that parent attendance is a necessary, but often not sufficient, factor underlying parent participation in services. For the current sample, we do not have observer reports of parents’ actual level of participation within in session, nor do we have any indicators of homework completion. These are clear directions for future research. Third, since children and families were recruited after they were already receiving services, we do not have information for the current sample as to why the child was served in outpatient vs school-based mental health services. It is possible that less involved parents may be more likely to seek school-based services, helping to explain the lower attendance in school-based services observed in the current study. There are a number of potential complex factors that determine service location (e.g. funding source for mental health services [Medicaid vs. Special Education funding], availability of services, structure of school district mental health services [contracted with community-based agency vs. district employees]). Lastly, this study did not address teacher engagement in child mental health services. The focus of this study is testing the effectiveness of training therapists delivering mental health (i.e. psychotherapy/counseling) services delivered in outpatient and school-based services. Future research may also examine how teachers may be engaged in school-based mental health services.

Conclusion

The current study offers an opportunity to examine the effectiveness of training outpatient and school-based mental health therapists in an intervention model for ASD in promoting parent attendance. Results suggest that training therapists in AIM HI resulted in significant improvements in parent attendance in their children’s mental health services across service settings. Further, the effect of AIM HI training was stronger in school-based settings, where parent attendance in mental health services has been historically challenging.

Acknowledgements

Funding

This study was funded by NIMH Grants R01MH094317 and K23MH115100.

References

  1. Atkins MS, Hoagwood KE, Kutash K, & Seidman E (2010). Toward the integration of education and mental health in schools. In Administration and Policy in Mental Health and Mental Health Services Research (Vol. 37, pp. 40–47). 10.1007/s10488-010-0299-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Barnett ML, Lau AS, Lind T, Wright B, Stadnick N, Innes-gomberg D, Pesanti K & Brookman-Frazee L (2019). Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children. Journal of Clinical Child & Adolescent Psychology, 00(00), 1–15. 10.1080/15374416.2019.1683851 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Becker KD, Boustani M, Gellatly R, & Chorpita BF (2018). Forty Years of Engagement Research in Children’s Mental Health Services: Multidimensional Measurement and Practice Elements. Journal of Clinical Child and Adolescent Psychology, 47(1), 1–23. 10.1080/15374416.2017.1326121 [DOI] [PubMed] [Google Scholar]
  4. Becker KD, Lee BR, Daleiden EL, Lindsey M, Brandt NE, & Chorpita BF (2015). The common elements of engagement in children’s mental health services: Which elements for which outcomes? Journal of Clinical Child and Adolescent Psychology, 4416(February 2014), 37–41. 10.1080/15374416.2013.814543 [DOI] [PubMed] [Google Scholar]
  5. Brannan Ana Maria, Heflinger CA, & Bickman L (1997). The Caregiver Strain Questionnaire. Journal of Emotional and Behavioral Disorders, 5(4), 212–222. 10.1177/106342669700500404 [DOI] [Google Scholar]
  6. Brannan Ana María, Heflinger CA, & Foster EM (2003). The role of caregiver strain and other family variables in determining children’s use of mental health services. Journal of Emotional and Behavioral Disorders, 11(2), 77–91. 10.1177/106342660301100202 [DOI] [Google Scholar]
  7. Brookman-Frazee L, Baker-Ericzén MJ, Stahmer A, Mandell DS, Haine RA, Hough RL, & Manuscript A (2009). Involvement of Youths with Autism Spectrum Disorders or Intellectual Disabilities in Multiple Public Service Systems. J Ment Health Res Intellect Disabil, 2(3), 201–219. 10.1080/19315860902741542.Involvement [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brookman-Frazee L, Chlebowski C, Villodas M, Villodas S, & Martinez K (2020). Training Community Therapists to Deliver a Mental Health Intervention for ASD: Changes in Caregiver Outcomes and Mediating Role on Child Outcomes. Journal of the American Academy of Child & Adolescent Psychiatry. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Brookman-Frazee L, & Drahota A (2010). An individualized mental health intervention for children with autism spectrum disorders (AIM HI): A model to address challenging behaviors in children with ASD—a therapist manual. Brookman-Frazee. Univeristy of California, San Diego, San Diego, CA [Google Scholar]
  10. Brookman-Frazee L, Drahota A, & Chlebowski C (2016). An individualized mental health intervention for children with autism spectrum disorders (AIM HI): A model to address challenging behaviors in children with ASD-A therapist manual: Version 2. Univeristy of California, San Diego, San Diego, CA. [Google Scholar]
  11. Brookman-Frazee L, Drahota A, Chlebowski C, Koenig Y, Williams K, Hill B, & McPherson J (2020). Designing ASD interventions for community implementation: Addressing children’s challenging behaviors in publicly-funded mental health services. In White SW (Ed.), Oxford Handbook of Autism and Co-Occurring Psychiatric Conditions (Oxford Uni; ). New York, NY. [Google Scholar]
  12. Brookman-Frazee L, Drahota A, Stadnick N, & Palinkas LA (2012). Therapist perspectives on community mental health services for children with Autism Spectrum Disorders. Administration and Policy in Mental Health and Mental Health Services, 39(5), 365–373. 10.1037/t38826-000 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Brookman-Frazee L, Roesch S, Chlebowski C, Baker-Ericzén MJ, & Ganger W (2019). Effectiveness of Training Therapists to Deliver An Individualized Mental Health Intervention for Children With ASD in Publicly Funded Mental Health Services. JAMA Psychiatry, 0812, 1–10. 10.1001/jamapsychiatry.2019.0011 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Brookman-Frazee L, Taylor R, & Garland AF (2010). Characterizing Community-Based Mental Health Services for Children with Autism Spectrum Disorders and Disruptive Behavior Problems. Journal of Autism and Developmental Disorders, 40(10), 1188–1201. 10.1007/s10803-010-0976-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Brookman-Frazee L, Vismara L, Drahota A, Stahmer A, & Openden D (2009). Parent Training Interventions for Children with Autism Spectrum Disorders. In Applied Behavior Analysis for Children with Autism Spectrum Disorders (pp. 237–257). New York, NY: Springer New York. 10.1007/978-1-4419-0088-3_14 [DOI] [Google Scholar]
  16. Burnett-Zeigler I, & Lyons JS (2010). Caregiver Factors Predicting Service Utilization Among Youth Participating in a School-based Mental Health Intervention. Journal of Child and Family Studies, 19(5), 572–578. 10.1007/s10826-009-9331-5 [DOI] [Google Scholar]
  17. Burns BJ, Erkanli A, Tweed D, Angold A, Farmer EMZ, Stangl D, & Costello EJ (2003). Children’s Mental Health Service Use Across Service Sectors. Health Affairs, 14(3), 147–159. 10.1377/hlthaff.14.3.147 [DOI] [PubMed] [Google Scholar]
  18. Burrell TL, & Borrego J (2012). Parents’ Involvement in ASD Treatment: What Is Their Role? Cognitive and Behavioral Practice, 19(3), 423–432. 10.1016/j.cbpra.2011.04.003 [DOI] [Google Scholar]
  19. Cohrs AC, & Leslie DL (2017). Depression in Parents of Children Diagnosed with Autism Spectrum Disorder: A Claims-Based Analysis. Journal of Autism and Developmental Disorders, 47(5), 1416–1422. 10.1007/s10803-017-3063-y [DOI] [PubMed] [Google Scholar]
  20. Constantino JN, & Gruber CP (2012). Social Responsiveness Scale, Second Edition. Los Angeles, CA: Western Psychological Services; [Google Scholar]
  21. Dickson KS, Zeedyk SM, Martinez J, & Haine-Schlagel R (2017). Examining ethnic disparities in provider and parent in-session participation engagement. Journal of Children’s Services, 12(1). 10.1108/JCS-12-2016-0022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Dowell KA, & Ogles BM (2010). The effects of parent participation on child psychotherapy outcome: A meta-analytic review. Journal of Clinical Child & Adolescent Psychology, 39, 151–162. 10.1080/15374410903532585 [DOI] [PubMed] [Google Scholar]
  23. Drahota A, Stadnick N, & Brookman-Frazee L (2014). Therapist Perspectives on Training in a Package of Evidence- Based Practice Strategies for Children with Autism Spectrum Disorders Served in Community Mental Health Clinics. Administration and Policy in Mental Health and Mental Health Services Research, 41(1), 114–125. 10.1016/j.immuni.2010.12.017.Two-stage [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Dyson M, Chlebowski C, & Brookman-Frazee L (2018). Therapists’ Adaptations to an Intervention to Reduce Challenging Behaviors in Children with Autism Spectrum Disorder in Publicly Funded Mental Health Services. Journal of Autism and Developmental Disorders, 49(3), 924–934. 10.1007/s10803-018-3795-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Evans SW, Owens JS, Wymbs BT, Ray AR, & Raisa A (2018). Evidence-Based Psychosocial Treatments for Children and Adolescents With Attention Deficit/ Hyperactivity Disorder. Journal of Clinical Child & Adolescent Psychology, 47(2), 157–198. 10.1080/15374416.2017.1390757 [DOI] [PubMed] [Google Scholar]
  26. Falk NH, Norris K, & Quinn MG (2014). The Factors Predicting Stress, Anxiety and Depression in the Parents of Children with Autism. Journal of Autism and Developmental Disorders, 44(12), 3185–3203. 10.1007/s10803-014-2189-4 [DOI] [PubMed] [Google Scholar]
  27. Farmer EMZ, Burns BJ, Phillips SD, Angold A, & Costello EJ (2003). Pathways into and through mental health services for children and adolescents. Psychiatric Services, 54(1), 60–66. 10.1176/appi.ps.54.1.60 [DOI] [PubMed] [Google Scholar]
  28. Fazel M, Hoagwood K, Stephan S, & Ford T (2014). Mental health interventions in schools in high-income countries. The Lancet Psychiatry, 1(5), 377–387. 10.1016/S2215-0366(14)70312-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Garland AF, Haine-Schlagel R, Accurso EC, Baker-Ericzén MJ, & Brookman-Frazee L (2012). Exploring the impact of therapists treatment practices on client attendance in community-based care for children. Psychological Services, 9(1), 74–88. 10.1037/a0027098.Exploring [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. George MM, Mcdaniel HL, Michael K, & Weist MD (2014). Clinician and Caregiver Perspectives on Family Involvement in School Mental Health Services for Youth Receiving Mood Disorders Treatment. Report on Emotional and Behavioral Disorders in Youth, 14(1), 16–21. Retrieved from https://www.researchgate.net/publication/260059892 [Google Scholar]
  31. Gopalan G, Burton G, McKay MM, & Rosenzweig JM (2008). Achieving school-family collaboration for children with emotional or behavioral disorders. In Rosenzweig JM & Brennan EM (Eds.), Work, Life, and the Mental Health System of Care: A Guide for Professionals Supporting Families of Children with Emotional or Behavioral Disorders. (1st ed.). Baltimore, MH: Brookes Publishing. [Google Scholar]
  32. Gopalan G, Goldstein L, Klingenstein K, Sicher C, Blake C, & McKay MM (2010). Engaging families into child mental health treatment: updates and special considerations. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 19(3), 182–196. [PMC free article] [PubMed] [Google Scholar]
  33. Guan K, Lau AS, Zhang A, Chlebowski C, Haine-Schlagel R, & Brookman-Frazee L (2019). In-Session Caregiver Behaviors during Evidence-Based Intervention Delivery for Children with ASD in Community Mental Health Services. Evidence-Based Practice in Child and Adolescent Mental Health, 4(1), 55–71. 10.1080/23794925.2019.1565500 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Haine-Schlagel R, Brookman-Frazee L, Fettes DL, Baker-Ericzén MJ, & Garland AF (2012). Therapist Focus on Parent Involvement in Community-Based Youth Psychotherapy. Journal of Child and Family Studies, 21, 646–656. 10.1007/s10826-011-9517-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Haine-Schlagel R, Martinez JI, Roesch SC, Bustos CE, & Janicki C (2016). Randomized Trial of the Parent And Caregiver Active Participation Toolkit for Child Mental Health Treatment. Journal of Clinical Child and Adolescent Psychology, 4416(July), 1–11. 10.1080/15374416.2016.1183497 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Haine-Schlagel R, & Walsh NE (2015). A Review of Parent Participation Engagement in Child and Family Mental Health Treatment. Clinical Child and Family Psychology Review, 18(2), 133–150. 10.1007/s10567-015-0182-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Hair JF, Black WC, Babin BJ, Anderson RE, & Tatham RL (2006). Multivariate data analysis (Vol. 6). [Google Scholar]
  38. Hayes SA, & Watson SL (2013). The impact of parenting stress: A meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(3), 629–642. 10.1007/s10803-012-1604-y [DOI] [PubMed] [Google Scholar]
  39. Higa-McMillan CK, Francis SE, Rith-najarian L, & Chorpita BF (2016). Evidence Base Update : 50 Years of Research on Treatment for Child and Adolescent Anxiety. Journal of Clinical Child & Adolescent Psychology, 45(2), 91–113. 10.1080/15374416.2015.1046177 [DOI] [PubMed] [Google Scholar]
  40. Israel P, Thomsen PH, Langeveld JH, & Stormark KM (2007). Child factors associated with parent involvement in usual clinical care of children and adolescents: A national register study. Nordic Journal of Psychiatry, 61(3), 173–181. 10.1080/08039480701352363 [DOI] [PubMed] [Google Scholar]
  41. Johnston C, & Mash EJ (1989). A Measure of Parenting Satisfaction and Efficacy. Journal of Clinical Child Psychology, 18(2), 167–175. 10.1207/s15374424jccp1802_8 [DOI] [Google Scholar]
  42. Kaminski JW, & Claussen AH (2017). Evidence Base Update for Psychosocial Treatments for Disruptive Behaviors in Children. Journal of Clinical Child & Adolescent Psychology, 46(4), 477–499. 10.1080/15374416.2017.1310044 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Khanna R, Madhavan SS, Smith MJ, Patrick JH, Tworek C, & Becker-Cottrill B (2011). Assessment of health-related quality of life among primary caregivers of children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 41(9), 1214–1227. 10.1007/s10803-010-1140-6 [DOI] [PubMed] [Google Scholar]
  44. Langley AK, Nadeem E, Kataoka SH, Stein BD, & Jaycox LH (2010). Evidence-Based Mental Health Programs in Schools: Barriers and Facilitators of Successful Implementation. School Mental Health, 2(3), 105–113. 10.1007/s12310-010-9038-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Lord C, DiLavore M, Risi PC, Gotham K, & Bishop S (2012). Autism Diagnostic Observation Schedule, Second Edition. Torrance, CA: Western Psychological Services. [Google Scholar]
  46. Mandell DS, Wiggins LD, Carpenter LA, Daniels J, DiGuiseppi C, Durkin MS, … Kirby RS (2009). Racial/ethnic disparities in the identification of children with autism spectrum disorders. American Journal of Public Health, 99(3), 493–498. 10.2105/AJPH.2007.131243 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Mark TL, Coffey RM, Vandivort-Warren R, Harwood HJ, King EC, & the MHSA Spending Estimates Team. (2005). U.S. Spending For Mental Health And Substance Abuse Treatment, 1991–2001. Health Affairs, 24(Suppl1), W5–133–W5–142. 10.1377/hlthaff.W5.133 [DOI] [PubMed] [Google Scholar]
  48. McCart MR, & Sheidow AJ (2016). Evidence-Based Psychosocial Treatments for Adolescents With Disruptive Behavior. Journal of Clinical Child & Adolescent Psychology, 45(5), 529–563. 10.1080/15374416.2016.1146990 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Mendez LR, Ogg J, Loker T, & Fefer S (2013). Including Parents in the Continuum of School-Based Mental Health Services: A Review of Intervention Program Research From 1995 to 2010. Journal of Applied School Psychology, 29(1), 1–36. 10.1080/15377903.2012.725580 [DOI] [Google Scholar]
  50. National Autism Center. (2015). Findings and Conclusions: National Standards Project, Phase 2. Randolph, Massachusetts. [Google Scholar]
  51. Pellecchia M, Nuske HJ, Straiton D, McGhee Hassrick E, Gulsrud A, Iadarola S, … Stahmer AC (2018). Strategies to Engage Underrepresented Parents in Child Intervention Services: A Review of Effectiveness and Co-occurring Use. Journal of Child and Family Studies. 10.1007/s10826-018-1144-y [DOI] [Google Scholar]
  52. Pereira AI, & Barros L (2019). Parental Cognitions and Motivation to Engage in Psychological Interventions: A Systematic Review. Child Psychiatry and Human Development, 50(3), 347–361. 10.1007/s10578-018-0852-2 [DOI] [PubMed] [Google Scholar]
  53. Postorino V, Sharp WG, McCracken CE, Bearss K, Burrell TL, Evans AN, & Scahill L (2017). A Systematic Review and Meta-analysis of Parent Training for Disruptive Behavior in Children with Autism Spectrum Disorder. Clinical Child and Family Psychology Review, 20(4), 1–12. 10.1007/s10567-017-0237-2 [DOI] [PubMed] [Google Scholar]
  54. Pullmann MD, Vanhooser S, Hoffman C, & Heflinger CA (2010). Barriers to and supports of family participation in a rural system of care for children with serious emotional problems. Community Mental Health Journal, 46(3), 211–220. 10.1007/s10597-009-9208-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Stadnick N, Drahota A, & Brookman-Frazee L (2013). Parent Perspectives of an Evidence-Based Intervention for Children with Autism Served in Community Mental Health Clinics. Journal of Child and Family Studies, 22(3), 414–422. 10.1007/s10826-012-9594-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Stadnick N, Haine-Schlagel R, & Martinez J (2016). Using Observational Assessment to Help Identify Factors Associated with Parent Participation Engagement in Community-Based Child Mental Health Services. Child and Youth Care Forum, 45(5), 745–758. 10.1007/s10566-016-9356-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Stahmer AC, & Pellecchia M (2015). Moving towards a more ecologically valid model of parent-implemented interventions in autism. Autism, 19(3), 259–261. 10.1177/1362361314566739 [DOI] [PubMed] [Google Scholar]
  58. StataCorp. (2017). Stata Statistical Software: Release 15. College Station, Tx.: StataCorp LLC. [Google Scholar]
  59. State of California Assembly Bill 114, Pub. L. No. Assembly Bill 114 (2011). Retrieved from http://leginfo.ca.gov/pub/11-12/bill/asm/ab_0101-0150/ab_114_bill_20110630_chaptered.pdf
  60. Sun M, Rith-Najarian LR, Williamson TJ, & Chorpita BF (2019). Treatment Features Associated with Youth Cognitive Behavioral Therapy Follow-Up Effects for Internalizing Disorders: A Meta-Analysis. Journal of Clinical Child and Adolescent Psychology, 48(sup1), S269–S283. 10.1080/15374416.2018.1443459 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. U.S. Department of Education. (2004). Individuals with Disabilities Education Improvement Act (IDEA).
  62. Vetter JA (2018). Parent-Child Interaction Therapy for Autism Spectrum and Attention-Deficit/Hyperactivity Disorders: A Review of the Literature. Child and Family Behavior Therapy, 40(3), 204–232. 10.1080/07317107.2018.1487740 [DOI] [Google Scholar]
  63. Whitaker K, Associates E, Bruns EJ, Lyon AR, & Pullmann M (2018). How Do School Mental Health Services Vary Across Contexts? Lessons Learned from Two Efforts to Implement a Research-Based Strategy. School Mental Health, 10(2), 134–146. 10.1007/s12310-017-9243-2 [DOI] [Google Scholar]
  64. Wong C, Odom SL, Hume KA, Cox AW, Fettig A, Kucharczyk S, … Schultz TR (2015). Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder: A Comprehensive Review. Journal of Autism and Developmental Disorders, 45(7), 1951–1966. 10.1007/s10803-014-2351-z [DOI] [PubMed] [Google Scholar]
  65. Woodard GS, Triplett NS, Martin P, Meza RD, Lyon AR, Berliner L, & Dorsey S (2019). Implementing Mental Health Services for Children and Adolescents : Caregiver Involvement in School-Based Care. Psychiatric Services, 1–4. 10.1176/appi.ps.201900160 [DOI] [PubMed] [Google Scholar]
  66. Wright B, Lau AS, & Brookman-Frazee L (2019). Factors Associated with Caregiver Attendance in the Community Implementation of Multiple Evidence-Based Practices in Children’s Mental Health Services. Psychiatric Services, 70(9), 808–815. 10.1176/appi.ps.201800443 [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES