4 - (SYM 110) Addressing Barriers to Engagement and Child Outcome Trajectories in Community Mental Health Care Settings: Underlying Challenges and Opportunity Costs

Background: Youth served in publicly funded community mental health services (CMHS) exhibit lower rates of symptom change and a higher likelihood of worsened symptoms compared to youth served in private managed care settings. Factors including low engagement and high attrition from care among marginalized youth and families limit the benefit of Evidence Based Practice (EBP) implementation in community settings, emphasizing a need for effective engagement strategies to reduce inequities. While addressing barriers is often employed to increase engagement, a recent study of EBP implementation in CMHS revealed therapists’ use of Addressing Barriers techniques was associated with less improvement in youth internalizing symptoms, suggesting overuse of Addressing Barriers may represent a negative quality indicator. This association may reflect underlying engagement challenges or inadvertent displacement of time spent on other EBPs.



Method: To identify targets for improving outcomes of youth EBP implementation in CMHS, the study examined the relation between youth and caregiver engagement challenges, therapists’ use of addressing barriers, and clinical outcomes. Data was collected from a naturalistic study of EBP implementation in CMHS from 2,351 sessions with 248 children (Mage=11.8; 49.6% girls, 1.2% non-binary; 78% Hispanic and 12% non-Hispanic white) delivered by 117 community therapists. Multilevel modeling with random intercepts and slopes was used.



Results: There is a significant indirect effect of caregiver engagement challenges on child internalizing symptom trajectories via therapists’ use of Addressing Barriers techniques, β = .701, SE = .337, p = .038. However, child engagement challenges did not exert the same effect. Further analyses will evaluate a displacement hypothesis—Addressing Barriers is linked to poorer outcomes because addressing engagement problems limits the time spent on other potent EBP elements.

Implications: This study addresses the critical need to evaluate youth EBP implementation in CMHS to advance mental health equity. Findings suggest poorer child outcome trajectories reflect underlying engagement challenges rather than a result of Addressing Barriers. This highlights a need for ongoing engagement monitoring and giving therapists proactive support for at-risk cases. Support for the displacement hypothesis would suggest a need for additional training to help therapists integrate Addressing Barriers with other key EBP elements that propel therapeutic change.