Provider and Caregiver Perspectives on Disparities in the Delivery of Evidence-Based Strategies in Publicly-Funded Mental Health Services: Implications for Intervention and Provider Training Models

Background: There are well-documented ethnic/racial disparities in access to and quality of community services for children with ASD. It is not known, however, if disparities persist when providers are trained to deliver evidence-based (EB) interventions. Understanding the role of cultural factors associated with treatment process when providers are delivering EB interventions is critical to tailoring interventions to fit the needs of client receiving care in community services.

Objectives: Gather community provider and caregiver perspectives to characterize disparities in delivery of mental health intervention for ASD and identify key adaptations to treatment and provider training protocols.

Methods: Data were collected in the context of a community effectiveness trial of AIM HI, an intervention designed to reduce challenging behaviors in the context of mental health services. Qualitative data were collected to complement and expand findings from the parent study. Participants included a subset of individuals enrolled in the effectiveness trial, including 17 therapists who participated in AIM HI training and 29 Hispanic caregivers (66% who speak Spanish as their primary language) whose child received mental health care from therapists trained in AIM HI. Data were obtained from the following sources: 1) therapist focus groups and individual interviews and 2) caregiver interviews.

Results: Themes regarding provider and caregiver perspectives were consistent with quantitative findings from observational session data from the parent study indicating few differences in treatment process by caregiver ethnicity. Qualitative data expanded to indicate that differences in treatment process were primarily related to client and caregiver education and social economic status (SES). The following factors were identified as influencing treatment process by therapists: (1) level of caregiver mental health literacy, including expectation regarding caregiver involvement; (2) caregiver understanding of ASD and its impact on child behaviors; (3) Caregiver primary language, including the complexity of conducting treatment through a translator or application of behavioral terminology when sessions were conducted in Spanish; (4) The cultural factors including the value of respeto and caregiver deference to providers, the influence of extended family members expectations of treatment, stigma, and the alignment of parenting values and a behavioral approach. Themes from caregiver interviews highlighted pragmatic variables influencing treatment, including logistics and time required to complete session activities and between session practice. Therapists also identified adaptations to the clinical intervention and therapist training l to address differences in treatment process including (1) changing the pacing of intervention to leave time for psychoeducation regarding ASD, (2) modifying materials to reduce technical terminology and increase “parent friendly” language to support understanding and home practice, and (3) explicit attention to new areas during AIM HI training, including how to deliver AIM HI with translators, key areas of psychoeducation, and incorporating cultural values in collaborative process with parents and identification of behavioral strategies.

Conclusions: This study was conducted as part of a broader line of research using community partnered approaches to intervention development and refinement. Results illustrate key issues that may influences disparities in treatment process and feasible adaptations to ensure the fit of interventions to families served in publically–funded mental health settings.