Table 2.

Compilation of possible ripple effects of children’s mental health services implementation strategies.

Ripple effect category and ripple effects within each category	Description of Ripple effect or category
1. General knowledge, skills, attitudes, and confidence about using evidence-based interventions (n = 8)	Any impact on tde knowledge, skills, attitudes, and confidence of tderapists, clients, caregivers, or otders regarding tde use of an evidence-based intervention.
Confidence/Self-efficacy in using EBIs	One's belief in their capacity to use an EBI with fidelity.
Skills in using EBIs	One's actual ability to use an EBI with fidelity.
Knowledge of EBIs	Facts and information about EBIs.
Beliefs in provider's competence to use EBIs	A perception of one's provider having sufficient knowledge, judgment, and/or skills in using EBIs.
Overspecialization in EBIs	To specialize in one or a few EBIs to such a degree as other EBIs are neglected.
Feelings of regret for not having used EBIs with past clients	Feeling guilt, remorse, or regret for previously implemented, non-EBI treatment practices.
EBI Intervention fatigue	A feeling of being overwhelmed by replacing or supplementing old knowledge and skills with new knowledge and skills, or from trying to learn and master too many varying EBIs.
Positive attitude and supportiveness of EBI	Degree of support for and belief in the effectiveness of EBIs; includes the amount of hope for improvement resulting from the EBI.
2. General job-related ripple effects (n = 6)	Attitudes, feelings, beliefs about one's job and outcomes associated with those attitudes such as worker retention, job satisfaction, and job burnout.
Job satisfaction	The attitudes clinicians, peer support providers, policy makers, or others have about their job as compared to previous experiences, current expectations, or available alternatives.
Job burnout	Feelings of emotional exhaustion, reduced personal accomplishment, loss of work fulfillment, and reduced effectiveness.
Job retention	Percentage of clinicians, peer support providers, policy makers, or others who stay in their job each year.
Job autonomy or independence	A feeling of independence and self-determination; ability to make your own decisions and act mostly on your own. When autonomy decreases, one might feel micromanaged.
Job workload/work burden	Feelings of burden associated with the amount or difficulty of one's work
Sense of job security	Feeling that the possibility of losing one's job is very low.
3. EBI treatment adherence, fidelity, and alignment (n = 3)	The degree to which EBIs are delivered by therapists in a way that is consistent with EBI training.
Provider EBI treatment fidelity	Whether an EBI intervention is implemented as planned and each component is delivered with competence.
Provider mixing of practice elements or cherry-picking practices	Using elements from multiple EBIs in a single practice, incorporating non-EBI elements (for example, dream analysis) into treatment, or using only practices deemed more useful or easier (e.g., teaching relaxation techniques).
Provider using “off-label” treatment	Implementing a mental health intervention for a disorder that it was not originally designed to treat. Using a treatment that the clinician knows how to do rather than the treatment most appropriate for the client.
4. Gaming the system (n = 4)	Manipulating data or practice to achieve the image of an outcome that is not consistent with the spirit of the practice.
Data gaming	Manipulating a data tracking, client management, or progress rewards system for a desired outcome.
Treatment counterfeiting	Delivering a treatment that is supposed to be a particular EBI but in reality lacks the essential elements of the EBI.
Tokenism	Recruiting people from underrepresented groups to provide feedback or be engaged as advisory board members solely to give the appearance of equality and engagement.
Insufficient use of data tracking systems	Providers only entering the minimum amount of data necessary to ensure payment or client tracking, and not using the data system as intended.
5. Equity and stigma (n = 3)	Equity related to treatment availability, access, quality, and outcomes by race, ethnicity, or other identity group classification; stigma associated with mental health.
Racial/ethnic prejudice	Being seen as one's racial or ethnic identity rather than individuals.
Equity	Reduction or elimination of disparities (e.g., access to services) between groups stemming from reduction of biases, removal of barriers, and/or inclusion of diverse perspectives.
Stigma around mental health issues	Stereotypes or negative views attributed to a person or groups of people when their mental health and/or behaviors are viewed as different from or inferior to societal norms.
6. Shifting roles, role clarity, task shifting (n = 2)	The degree to which the new intervention requires roles that clarifies or conflicts with existing roles, or changes role responsibilities.
Role clarity	The degree to which the new intervention clarifies and distinguishes between existing roles, tasks, responsibilities, and processes. The opposite of role conflict, blurred roles, or turf battles.
Task shifting	When some mental health treatment tasks that had previously been done by therapists are assigned to health workers, peer providers, or others with shorter training and fewer academic qualifications.
7. Economic costs and benefits (n = 4)	Any monetary cost or benefit of the use of the implementation strategy.
Income	Amount of money one makes at one's job.
Ability to bill insurance for an EBI	The ability of therapists to bill insurance plans for a particular EBI or mental health service.
Budget implications	Expected impacts on income and expenditures for agencies or state public mental health budgets.
Monetary costs	Monetary costs of the implementation strategy.
8. EBI treatment availability, access, participation, attendance, barriers & facilitators (n = 8)	The availability of an EBI in a region (e.g., whether there is a provider that is trained on the EBI), whether the EBI is accessible (e.g., whether there is no waiting list or other barriers to accessing the treatment), the actual use of and client participation in the EBI, and any barriers or facilitators that support the availability, access, and use of services
Service availability, access, and reach	The presence or availability of services and spread of those services across a region—this requires a provider who is trained on the EBI.
Facilitators of treatment	Something that facilitates, makes easier, or supports a client’s ability to attend, engage in or complete treatment. Facilitators can be at the client level, logistic, or other facilitators. Client-level facilitators might be attitudes (belief treatment will work, belief in the need for treatment), emotional, or behavioral strengths in individuals and groups. Logistic facilitators to treatment include things such as insurance coverage, good transportation, and proximity to treatment.
Barriers to treatment	Something that restricts, impedes, or blocks client ability to attend, engage, or complete treatment. Barriers can be at the client level, logistic, or other barriers. Client-level barriers might be attitudes (stigma, feeling treatment might not work), emotional, or behavioral limitations in individuals and groups. Logistic barriers to treatment include things such as cost, transportation issues, and location.
Participation or attendance at treatment sessions	The degree to which the youth, client, or caregiver is involved in the client's treatment sessions.
Client adherence to treatment recommendations	The degree to which the behavior of youth clients or their caregivers corresponds with recommendations from therapists.
Client transfer/therapist change	Burden and/or instability felt by clients, families, and organizations resulting from changing providers.
De-implementation	When a clinical practice or approach to treatment (EBI or non-EBI) that was once offered is discontinued.
Sustainability	Percentage of implemented EBIs that sustain at yearly intervals.
9. Clinical process and treatment quality (n = 7)	The process of clinical treatment, including treatment quality, the focus, length, assessment burden, time spent in active treatment, and effects on treatment as usual.
Treatment quality and effectiveness	The degree to which the treatment is high-quality, meaning how effective, engaging, and efficient the treatment is at improving client functioning and symptoms.
Individualization of treatment goals and practice	Tailoring treatment goals and practices to the specific needs of the client.
Length of time until treatment completion	The length of time for a youth client to complete treatment.
Narrow focus on outcomes	Focusing treatment only on one major outcome, neglecting other needs the youth client may have.
Assessment burden	Perception of burden (e.g., hardship or distress) when administering or completing clinical assessments, surveys, and questionnaires.
Time providing or receiving active treatment	Amount of time a provider spends delivering or a client spends receiving active treatment during a session.
Improvement in quality of “usual treatment”	Improved quality and effectiveness of "treatment-as-usual," usual care, or non-EBI treatment.
10. Client engagement, therapeutic alliance, and client satisfaction (n = 5)	The degree to which clients are engaged and participating in the treatment planning and process, feelings of alliance and bond between client and therapist, and level of satisfaction with treatment.
Client engagement in treatment	The degree to which the client is engaged in treatment, such as participating during the session, being involved in treatment planning, and initiating contact or questions with the provider.
Clarity of understanding about client's needs and strengths, treatment purpose, and progress	The degree to which clinicians, clients, or their caregivers are informed about and understand the client's needs and strengths, the reasons for and goals of treatment, and the youth client's clinical progress.
Satisfaction with treatment	A client’s rating of important attributes of the process and outcomes of their treatment experience.
Youth client motivation/self-efficacy to accomplish treatment goals	Refers to a youth client's motivation and belief in their capacity to execute behaviors necessary to complete treatment. This reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment.
Therapeutic alliance	A cooperative working relationship between youth client and therapist. Includes youth's sense of being "heard" and responded to in therapy, shared understanding, shared goals, and working together for common therapeutic purpose.
11. Clinical organization structure, relationships in the organization, process, and functioning (n = 9)	Elements associated with the organization, structure, process, functioning, and relationships within the organization, including organizational climate, organization's use of resources, supervisory relationships, job applicant pool, and referral rates.
Administrative burden	Anything that is necessary to demonstrate compliance with a regulatory requirement, including the collecting, processing, reporting, and retaining of information, and the financial and economic costs of doing so.
Organization reputation	Refers to people’s collective opinion regarding the organization.
Organizational climate and culture	Employee's shared beliefs and values of an organization, and perceptions of the organization's policies, practices, procedures, and reward systems.
Referral rates	The rate of referrals to mental health treatment.
Quality of job applicant pool	Having a pool of qualified clinician applicants during the hiring process.
Opportunity costs	The loss of potential gain from other alternatives when one alternative is chosen.
Supervisor-therapist alliance	A partnership between a clinical supervisor and a clinician, devoted to the learning and growing of the clinician where there is a strong bond of care, respect, and trust.
Scalability	An attribute that describes the ability of a process, intervention, or organization to grow and manage increased demand.
Cross-organizational camaraderie	Mutual trust, support, friendship, and feelings of community among people.
12. Youth client and caregiver outcomes (n = 5)	Client and caregiver thoughts, feelings, behaviors, symptoms, and functioning.
Functioning and symptoms	How the client is functioning in the world, and the symptoms of their mental health problems. This could include symptoms like depression, anxiety, or unwanted thoughts, or functioning such as ability to care for themselves, incarceration/recidivism, school enrollment, graduation, out-of-home placements, employment, lifespan, etc.
Informal support systems	Informal support systems such as friends, family, religious supports, recreation groups, and online social networks.
Caregiver strain	The perception of persistent problems and a feeling of decreased well-being that results from providing prolonged care.
Empowerment	The degree to which one can represent or advocate for their interests, determine the progress of their mental health treatment, and claim their rights.
Re-traumatization	Clinical regression (worsening of symptoms or functioning) or new mental health crisis due to processing past traumas.
Hope	Hopefulness for the future, inspiration, a belief that the situation will improve.
13. Use of EBI strategies and insight in one's own life (n = 2)	The application of strategies and practices from an EBI in one's own life.
Using EBI strategies for self-care	Using EBI strategies in one's own life (such as deep breathing or behavioral activation).
Using EBI strategies with friends and family members	Helping friends and families by teaching them EBI strategies (such as deep breathing or behavioral activation), or using strategies with them such as reward systems.