Effectiveness of a Caregiver Mediated Intervention in Publicly -Funded Mental Health Services: Factors Associated with Improvements in Parenting Self-Efficacy

Background: AIM HI (“An Individualized Mental Health Intervention for ASD”, Brookman-Frazee and Drahota, 2010) was developed in response to the need for an implementable, evidence-based (EB) intervention for delivery in mental health service (MH) settings. AIM HI is a package of EB strategies designed to reduce challenging behaviors, the most common presenting problem for children with ASD in MH services. Active caregiver involvement in facilitating child skill development is a critical component of AIM HI and consistent with EB practices for ASD. Thus, the impact of treatment on parenting self-efficacy is an important outcome. There is limited research on the effectiveness of parent-mediated interventions when delivered by community providers. The current study examined the impact of training community providers in AIM HI on caregiver parenting self-efficacy. Data were drawn from a large-scale randomized community effectiveness trial of AIM HI conducted in publicly-funded outpatient and school-based MH programs.

Objectives: (1) Examine the impact of AIM HI on changes in parenting self-efficacy from baseline to 6 months. (2) Identify caregiver characteristics and session attendance, and therapist fidelity associated with changes in self-efficacy for caregivers in the AIM HI training condition.

Methods: A waitlist control design was used in which MH programs were randomized to either immediate AIM HI training or Usual Care/Delayed AIM HI training conditions. Therapist and client dyads were enrolled from participant programs. A total of 202 client/therapist dyads were included. Child participants were 84% male, an average of 9.13 years (SD=2.44) and 70% Hispanic. Caregivers were 93% female and 61% Hispanic. The Parenting Sense of Competence Scale (PSOC; Ohan et al., 2000) was the primary outcome measure used and was collected at baseline and after 6 months. Trainer, therapist and caregiver ratings of therapist fidelity were collected after 6 months.

Results: Results from two-level (time nested within client) mixed-effects model indicated a significant group by time interaction for parenting self-efficacy. Specifically, caregivers of children whose therapists completed AIM HI training reported significantly improved parenting self-efficacy compared to caregivers who received Usual Care, B = 3.22 (SE = 1.57), p <.05. To guide post-hoc analyses to probe this treatment effect, bivariate analyses were performed between each proposed predictor and PSOC scores for the AIM HI condition only. The three characteristics (ethnicity, baseline caregiver strain, and caregiver-rated therapist fidelity) that were significantly associated with parenting self-efficacy in the bivariate models were entered into a multilevel multivariable model. Results revealed a significant interaction between time and caregiver rated therapist fidelity, B = 2.57 (SE = 0.88), p <.01, indicating that caregiver perceptions of therapist fidelity (i.e., therapist use of active teaching skills directed towards the caregiver) was associated with improved parenting self-efficacy. Caregiver ethnicity and baseline caregiver strain did not moderate the treatment effect.

Conclusions: These results provide empirical support for the effectiveness of AIM HI on a key targeted outcome when delivered by community providers and highlight the importance of targeting therapist fidelity in bolstering clinical outcomes.