Aaron R. Lyon, Ph.D. - US grants

DESCRIPTION (provided by candidate): The majority of youth in need of mental health interventions do not receive any services (Kataoka et al., 2002). This problem is particularly notable among low socioeconomic (SES) and ethnic minority youth, who are most likely to experience mental health problems, least likely to receive services, and are consequently more likely to suffer the deleterious effects of mental health problems (US DHHS, 2001). School-based prevention and intervention programs represent one of the most promising opportunities for reducing identified service gaps and disparities among youth because of the nearly universal nature of primary and secondary education. As the most common point of entry into a fragmented mental health system, efforts to improve school-based services and understand their implications for future care carry profound implications for overall public health (Farmer et al., 2003). The current application is designed to provide training in the skills necessary to build a long-term program of research investigating the role of school-based programs in addressing the unmet mental health needs of diverse groups of youth. My overarching goal is to move toward an independent research career in which I will apply sophisticated research methodologies to the study and remediation of mental health gaps and disparities and apply the findings to the development of a service delivery model. To accomplish these goals, I will engage in an intensive training experience that will combine individual mentorship, coursework, and field experiences. This training will inform and shape the analyses of a set of research questions pertaining to mental health service utilization and form the basis for a Career Development grant application. The primary research component of this project will take advantage of a rich, existing data set from a school-based prevention program for adolescent depression, the High School Transition Study (HSTS;McCauley et al., 2008), to conduct analyses beyond the scope of the original study. The proposed project will allow me to build expertise in the analysis of school-related factors that influence program effectiveness and to gain knowledge about the assessment of program impact on mental health service utilization across service sectors (e.g., specialty mental health, primary care, education). Results will provide information about how school-based interventions fit into the overall service delivery system, and their potential for reducing disparities in access to services and youth outcomes. My specific research aims include using the ethnically and socioeconomically diverse HSTS sample to explore how students'school attachment and support mediate intervention outcome and to examine the impact of HSTS program participation on the mental health service utilization of different groups of youth.

DESCRIPTION (provided by applicant): This Mentored Career Development Award (K08) is designed to provide intensive training in developing a strong program of research that investigates the adaptation and implementation of health information technologies within the school context to increase the availability of high-quality mental health interventions for underserved youth and families. A field of implementation science has recently emerged to address the significant gap between the proliferation of evidence-based practices (EBP) for treating youth mental health problems and their use in usual care treatment settings. Nowhere is this gap more apparent than in schools. Schools provide the bulk of youth mental health services (>70%) and effectively reduce service access disparities by ethnicity and socioeconomic status. Nevertheless, implementation research focused on the school context has been disproportionately limited. To address these gaps and advance implementation science, the candidate's long term career objective is to develop effective methods for promoting the use of EBP among mental health providers in educational settings. Standardized assessment (SA) of psychiatric symptoms is a cornerstone of all EBP and has been significantly associated with improvements in treatment- related outcome. Nevertheless, SA is infrequently utilized by school-based providers, resulting in sub-optimal care. Measurement feedback systems (MFS) use the results of SA to deliver information to clinicians about client progress, represent a structured way to introduce SA into service systems, and have the potential to support effective, client-centered care. The candidate's immediate focus is therefore to increase clinicians' administration of SA tools and incorporation of SA feedback into routine practice through the development of a MFS and an accompanying contextualized adaptation process that are designed specifically for schools. The current K08 Award will uniquely position the candidate to advance this research agenda. His background includes specialized training in child clinical psychology, evidence-based assessment and intervention approaches, research on school-based mental health, mental health services research, and collaboration with community stakeholders. To more effectively bridge the gap between typical and optimal mental health care in schools, he seeks to extend his training to include: (1) design of healthcare technologies that are user-friendly and contextually appropriate, (2) experience with theory and methods to support innovation uptake/implementation in schools, (3) advanced statistics and research methodology, and (4) advanced academic writing. The University of Washington is an outstanding environment in which to engage in the interdisciplinary training required to achieve these training goals. The candidate's primary mentors-Drs. Elizabeth McCauley and Jurgen Unutzer have combined expertise in the assessment and treatment of adolescent psychopathology, training with school-based providers, development of computer products to support evidence-based service delivery, implementation science, and the development and dissemination of measurement feedback tools for client progress monitoring. Additional local and national consultants will contribute expertise in implementation research for youth/family services, user-centered design, school-based mental health, community service provision, decision support tools for youth treatment providers, cultural diversity and mental health care, mental health policy, and qualitative and mixed methods research. The proposed project draws on the training and expertise above to develop and evaluate a contextually- adapted, web-based MFS for use in school-based health centers (SBHCs) through a series of qualitative, quantitative, and mixed methods research aims. The University of Washington Care Management Tracking System is a MFS, developed by Dr. Unutzer, previously found to result in improved care, symptom reductions, and increased functioning among patients. The current study proposes to use SBHC clinician focus groups and direct clinician feedback to adapt this MFS for use by SBHC clinicians. The candidate's prior research has revealed that SBHC providers infrequently utilize SA measures, but supports the feasibility of using structured, computerized methods to increase SA administration. A sample of SBHC clinicians (n = 20) and youth (n = 64, Aim 3) will participate in the project to advance the following Research Aims: (1) evaluate the SBHC context to inform MFS adaptation; (2) assess the adaptation's effectiveness in context; (3) evaluate the system impact on clinician behavior and youth outcomes; and (4) assess the added utility of providing academic data to school clinicians for use in progress monitoring. SBHC clinicians will provide feedback on the optimal design of the MFS and use it to track outcomes among youth experiencing depression and anxiety. Aims 1 and 2 will be evaluated descriptively, using existing benchmarks when applicable. Aim 3 will be tested experimentally via a small-scale randomized trial in which clinicians (and a subset of their caseloads) will be randomized to one of two conditions: (a) use of the school MFS to monitor progress using SA or (b) assessment as usual. Aim 4 will be tested using the MFS, with randomization of youth to two conditions: (a) clinicians receive the results of SA and students' school attendance data from the MFS or (b) data include SA results only. Based on the results of this work, a R01 grant application will be submitted to investigate the larger-scale implementation of the school MFS and contextualized adaptation process among a range of school service delivery models, allowing for more thorough evaluation of its impact on clinician behavior and student functioning.

PROJECT SUMMARY Only about half of the youth in the United States who experience mental health problems receive indicated treatment, resulting in high societal cost. Evidence-based practices (EBP) for mental health conditions yield significant benefits to children when they are actually implemented with fidelity. Although 70 to 80% mental health services for youth are currently provided in schools, few students receive EBP. Barriers to EBP implementation in schools include both those at the organizational level (lack of funding, poor administrative support, high personnel turnover, inadequate training) as well as those at the individual level (perception of intervention acceptability and appropriateness, time demands, social norms, conflicting theoretical perspectives). Although significant attention has been devoted to categorizing implementation barriers and potential strategies, there have been few efforts to develop and test innovative interventions to enhance implementation. In schools, implementation initiatives often occur as top-down mandates without attention to the individual factors found to impact provider behavior, such as provider attitudes about, or intentions to implement EBP, following training. Failing to address these individual-level barriers is especially costly, as individual behavior change is ultimately required for successful EBP implementation, even when organizational factors (e.g., evidence-informed policy, supportive leadership, effective training) are in place. Consistent with the aims of the R21 mechanism, the goal of this study is to adapt and test the feasibility and potential efficacy of a theory-driven pre-implementation intervention to address individual-level barriers to EBP implementation ? Beliefs and Attitudes for Successful Implementation in Schools (BASIS) ? designed to improve school-based mental health providers' implementation of EBP. BASIS is intended to be a feasible and scalable first-line or adjunctive implementation enhancement intervention that is facilitative of other efforts (e.g., organizational interventions) that target high quality EBP implementation. Aims of this study are to: (1) Adapt an existing, theory-driven implementation intervention (BASIS), previously used with educators, to improve the EBP implementation behaviors of SBMH providers; and (2) Assess the viability of a later clinical trial by: (a) establishing the feasibility, acceptability, and appropriateness of the BASIS intervention among school-based mental health providers, and (b) pilot testing BASIS, as compared to an Attention Control, delivered as pre-implementation intervention prior to training in a specific, existing EBP. Key organizational factors (e.g., implementation climate) will also be evaluated and included as covariates and we will explore trends in the data to inform the design of a larger trial. Ultimately, BASIS offers an innovative and scalable approach to improving SBMH providers' uptake and use of EBP in order to increase the number of youth with mental health problems who receive high quality services.

PROJECT SUMMARY In the US, roughly one in five children experiences a mental health problem severe enough to warrant diagnosis and intervention. The education sector offers compelling opportunities to improve service access, but school mental health (SMH) providers are unlikely to deliver high-quality evidence-based practices (EBP), dramatically reducing the public health impact of these services. Multiple barriers interfere with SMH providers receiving adequate training and support in EBP, including limited time and scarce training resources. The goal of this project is to improve school-based care by developing and testing an online training and consultation system to facilitate use of routine outcome monitoring (ROM), an EBP with extensive empirical support and a feasible and cost-effective minimal intervention necessary for change. Although ROM is not routinely used by SMH providers, our preliminary work has found that targeted training can improve ROM uptake. Unfortunately, due to issues such as time, training resources, and practitioner geographic dispersion, especially in rural areas (<1 practitioner per school), ROM training is inaccessible to many SMH providers. Online training (OLT) addresses these barriers. In addition, because OLT is self-paced and flexible, it is associated with lower levels of provider burnout. OLT is also cost effective and scalable because its only requirements are internet access and server support. Regardless of the training modality, post-training consultation is essential for practitioner behavior change. To be optimally effective, consultation needs to be collaborative and responsive to learner needs. Using user-centered design methodology, which emphasizes iterative development of parsimonious and compelling products, the current R34 proposal will maximize the feasibility, usability, and efficiency of an innovative approach to OLT and follow-up consultation for SMH clinicians ? Brief Online Training (BOLT) for ROM. In Aim 1, we will develop the OLT platform via iterative prototyping and continuous user testing to optimize system usability and training's impact on provider knowledge and attitudes about ROM. In Aim 2, we will iteratively develop BOLT post-training consultation procedures to optimize putative mechanisms of effective consultation: consultant collaboration & responsiveness. In Aim 3, we will conduct a pilot randomized controlled trial of the full BOLT training/consultation package to test (1) BOLT effects on ROM knowledge, attitudes, and weekly assessments of ROM use; (2) the incremental impact of consultation dosage on ROM use; and (3) mechanisms of BOLT impact, including (a) platform usability, (b) clinician knowledge and attitude gains, (c) collaboration, and (d) responsiveness of consultation. This project will yield feasibility data to inform a subsequent effectiveness-implementation hybrid trial that will experimentally test BOLT mechanisms of change and its impact on youth outcomes.

PROJECT SUMMARY / ABSTRACT Integrated care is increasingly common, yet contemporary implementation frameworks typically assume a single organization within which system-level processes influence service quality and implementation success. This perspective does not represent the emerging realities of modern mental health care and inhibits what can be learned about organizational processes in implementation. Recent frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP). The proposed study will be the first to empirically examine this prediction. By expanding the focus of implementation science beyond single organizations, this project aims to improve implementation of mental health services in integrated care settings. School-based mental health (SBMH) services provide an important example of an integrated care setting, where two organizations with distinct, but related, objectives overlap. SBMH services are most frequently delivered by clinicians embedded in schools but employed by external community-based organizations (CBOs). Thus, the typical SBMH clinician is someone who functions within ? and whose practices are impacted by ? multiple organizational contexts. In integrated care settings, the unique and combined impact of the two overlapping organizations on any individual provider are likely to vary as a function of how embedded the provider is within each setting. SBMH provides a unique opportunity to examine organizational alignment as well as the impact of embeddedness. This study is the first to examine the specific impact of overlapping organizational contexts in which EBP implementation increasingly occurs. We will conduct exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and CBOs as they relate to mental health EBP implementation. We will estimate the effects of different aspects of the school and CBO organizational influences on the implementation outcomes identified as most critical to SBMH (fidelity, acceptability, appropriateness). We also will explore the mechanisms through which inter-organizational alignment influences implementation outcomes. Using a sample that represents the vast majority (>90%) of CBOs in two geographically distinct and diverse regions, we will address the following aims: Aim 1: Using quantitative methods, estimate the effects of (a) each intra-organizational implementation context (school and CBO) and (b) inter-organizational alignment (IOA) on implementation outcomes. Aim 1a: Estimate the moderating effect of clinicians' degree of school embeddedness on Aim 1 effects. Aim 2: Using a sequential mixed methods approach, examine the underlying mechanisms through which IOA facilitates or hinders EBP implementation.

PROJECT ABSTRACT Most youth who experience significant trauma-related symptoms do not receive indicated services and, when they do, the services received are not evidence-based. The education sector is responsible for 70-80% of all mental health services delivered to youth, but there are (1) a limited menu of evidence-based treatments (EBTs) for trauma available for use in schools and (2) a need to enhance the uptake and use of EBT in schools and other community settings for youth exposed to trauma. Trauma-focused cognitive behavior therapy (TF-CBT) is an efficacious treatment for trauma-exposed youth, but there are no studies that have evaluated the effectiveness of TF-CBT when delivered in schools. Additionally, significant implementation barriers limit the successful adoption, delivery with fidelity, and sustainment of TF-CBT; especially individual clinician variables, such as beliefs and attitudes surrounding core components of the intervention (e.g., exposure to feared stimuli). These two gaps reveal the need for research that simultaneously examines effectiveness and implementation of TF-CBT when delivered in schools. Individual provider behavior change is a critical component of successful implementation of any EBT. Even when factors such as evidence-informed policy, supportive leadership, and effective training are in place, implementation ultimately rests with providers? motivation and commitment to change. The Beliefs and Attitudes for Successful Implementation in Schools (BASIS) intervention is a facilitated, group-based blended implementation strategy. BASIS is brief, pragmatic, and is designed to augment standard EBP training and consultation procedures. It targets theoretically-derived individual-level determinants associated with behavior change using motivational and volitional behavior change strategies. BASIS has been rated as feasible and appropriate by SBMH clinicians, and found to increase clinicians? attitudes, perceptions of social norms, and implementation intentions to use EBT in a small (n = 24) randomized trial (R21MH108714). Considering the need to examine the effectiveness of TF-CBT in the context of schools and the importance of individual-level strategies that augment EBT training and consultation, the current proposal is a hybrid type 2 effectiveness-implementation trial with 120 SBMH clinicians and 480 students using mixed methods. This project is designed to simultaneously test the effectiveness of TF-CBT in schools and the impact of BASIS on proximal mechanisms and TF-CBT implementation outcomes. Specifically, the proposal aims to experimentally evaluate TF-CBT in schools versus treatment as usual, including intervention mechanisms of change, mental health outcomes, and TF-CBT cost-effectiveness (Aim 1); and experimentally evaluate BASIS versus and attention control, including implementation mechanisms of change, TF-CBT implementation outcomes, and BASIS cost-effectiveness (Aim 2). TF-CBT and BASIS represent potentially robust and generalizable strategies for greatly enhancing the accessibility and quality of services for trauma-exposed youth.