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Effectiveness of a multi-level implementation strategy for ASD interventions: study protocol for two linked cluster
Lauren Brookman-Frazee1,2, Aubyn C Stahmer3,4
1Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0812, USA. lbrookman@ucsd.edu.
Insights
The Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy (TEAMS) model improves autism intervention implementation. TEAMS enhances leadership and provider training, leading to better child outcomes in mental health and education settings.
Area of Science:
- Implementation Science
- Public Health
- Child Psychology
Background:
- Autism Spectrum Disorder (ASD) affects 1 in 59 children, costing $236 billion annually in the U.S.
- Evidence-based interventions (EBIs) improve child outcomes but scaling them across systems is challenging.
- Limited research exists on generalizable methods to implement EBIs for ASD.
Purpose of the Study:
- To test the effectiveness of the TEAMS model in scaling up EBIs for ASD.
- To improve implementation leadership, organizational climate, and provider motivation.
- To enhance provider training completion, intervention fidelity, and child outcomes.
Main Methods:
- A cluster randomized hybrid type 3 trial with a dismantling design.
- Study #1: TEAMS with AIM HI in mental health services. Study #2: TEAMS with CPRT in education settings.
- Randomized 37 mental health programs and 37 school districts into four groups to test TEAMS modules.
Main Results:
- Examined implementation outcomes including provider training completion and fidelity.
- Child behavior change was assessed for mental health providers, teachers, and children.
- The study design allows for understanding mechanisms of change across settings and participants.
Conclusions:
- The TEAMS model has the potential to increase the quality of ASD care in publicly funded settings.
- The TEAMS process and modules are generalizable to multiple service systems, providers, and interventions.
- This approach offers broad impact for community services caring for children with ASD.
Background:
The Centers for Disease Control (2018) estimates that 1 in 59 children has autism spectrum disorder, and the annual cost of ASD in the U.S. is estimated to be $236 billion. Evidence-based interventions have been developed and demonstrate effectiveness in improving child outcomes. However, research on generalizable methods to scale up these practices in the multiple service systems caring for these children has been limited and is critical to meet this growing public health need. This project includes two, coordinated studies testing the effectiveness of the Translating Evidence-based Interventions (EBI) for ASD: Multi-Level Implementation Strategy (TEAMS) model. TEAMS focuses on improving implementation leadership, organizational climate, and provider attitudes and motivation in order to improve two key implementation outcomes-provider training completion and intervention fidelity and subsequent child outcomes. The TEAMS Leadership Institute applies implementation leadership strategies and TEAMS Individualized Provider Strategies for training applies motivational interviewing strategies to facilitate provider and organizational behavior change.
Methods:
A cluster randomized implementation/effectiveness Hybrid, type 3, trial with a dismantling design will be used to understand the effectiveness of TEAMS and the mechanisms of change across settings and participants. Study #1 will test the TEAMS model with AIM HI (An Individualized Mental Health Intervention for ASD) in publicly funded mental health services. Study #2 will test TEAMS with CPRT (Classroom Pivotal Response Teaching) in education settings. Thirty-seven mental health programs and 37 school districts will be randomized, stratified by county and study, to one of four groups (Standard Provider Training Only, Standard Provider Training + Leader Training, Enhanced Provider Training, Enhanced Provider Training + Leader Training) to test the effectiveness of combining standard, EBI-specific training with the two TEAMS modules individually and together on multiple implementation outcomes. Implementation outcomes including provider training completion, fidelity (coded by observers blind to group assignment) and child behavior change will be examined for 295 mental health providers, 295 teachers, and 590 children.
Discussion:
This implementation intervention has the potential to increase quality of care for ASD in publicly funded settings by improving effectiveness of intervention implementation. The process and modules will be generalizable to multiple service systems, providers, and interventions, providing broad impact in community services.
Trial Registration:
This study is registered with Clinicaltrials.gov ( NCT03380078 ). Registered 20 December 2017, retrospectively registered.
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