A Two-Generation, Early Childhood Advanced Primary Care Model.

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Volunteer Engagement within Equine Assisted Services.

This study examines the effect of volunteering within a Professional Association of Therapeutic Horsemanship International (PATH Intl) premiere accredited center by exploring the experiences of volunteers leading horses in adaptive riding lessons. Adaptive Riding lessons are horseback riding lessons for individuals ages four through the lifespan, with special needs, varying from cognitive, physical, social-emotional, or other challenges. Volunteers directly impact the rider-horse bond by increasing accessibility to horseback riding for individuals with disabilities, fostering a meaningful bond between the rider and horse. The research questions were as follows: (1) do saliva measures of cortisol and alpha-amylase (stress), and oxytocin (affiliative bonding) change over time for volunteers; and (2) how satisfied are volunteers with volunteering for Equine Assisted Services (EAS)? Forty-one volunteers participated in Reining in Anxiety, an intervention combining adaptive riding and cognitive behavioral therapy. Physiological data (i.e., pooled saliva, saliva combined from various glands throughout the mouth, resting under the tongue prior to collection) were collected pre/post riding session at four time points during the 10-session intervention, measuring oxytocin, cortisol, and alpha-amylase. Post-intervention, volunteers completed a survey about their experiences as volunteers and as participants in the study. All saliva samples were collected successfully. There was a non-significant, positive trend in oxytocin and alpha-amylase, while cortisol remained level. The responses in the survey suggested that volunteers perceive their role positively, with nuanced experiences of a sense of responsibility to ensure safety, and enjoyment in assisting the riders. Volunteers are vital to the safety of the rider and horse. While their perceived and internalized responsibility is evidenced by an increase in stress (e.g., cortisol remaining level and an increase in alpha-amylase), it is not necessarily negative stress, as there is simultaneously affiliative bonding expressed (oxytocin). The complex emotions and experiences of volunteers are important to understand to create meaningful, sustainable volunteer engagement. This is particularly important in the EAS industry, which is reliant on volunteerism.

PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference.

BACKGROUND: The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend. AIMS: This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE). METHODS: The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests. RESULTS: Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover. DISCUSSION: These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover. IMPLICATIONS FOR HEALTH CARE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness. IMPLICATIONS FOR HEALTH POLICIES: The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing. IMPLICATIONS FOR FURTHER RESEARCH: Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

Implementing a Child Mental Health Intervention in Child Welfare Services: Stakeholder Perspectives on Feasibility.

This pilot study integrated quantitative and qualitative data to examine the feasibility of implementing a modified version of a multiple family group behavioral parent training intervention (The 4Rs and 2Ss for Strengthening Families Program [4Rs and 2Ss]) in child welfare (CW) placement prevention services, from the perspectives of participating caregivers (n = 12) and CW staff (n = 12; i.e., 6 caseworkers, 4 supervisors, and 2 administrators). Quantitative surveys were administered to caregivers and CW staff followed by semi-structured interviews to examine the feasibility of implementing the modified 4Rs and 2Ss program, as well as factors impacting feasibility. Results indicated that quantitative benchmarks for high feasibility were met in all assessed areas (e.g., family recruitment, caseworker fidelity ratings, CW staff feasibility ratings) except for family attendance, which was markedly lower than desired. Factors facilitating feasibility included agency and research support, intervention ease-of-use, perceived benefits to existing CW practice, as well as logistical support (e.g., food, transportation, childcare) promoting attendance. Factors hindering feasibility included conflicts between research-based eligibility criteria and existing client population demographics, research-related processes resulting in delays, CW staff role conflicts, added workload burden, complex family issues, and power differentials inherent to CW services which complicated families' voluntary participation.

An Examination of the 4 Rs 2 Ss for Problem Behaviors: A Preventive Approach.

Early treatment of behavioral problems can prevent their progression into intractable disorders. This study examined the impact of a multiple family group (MFG) intervention for children with behavior symptoms and their families. Fifty-four (n = 54) caregiver/child dyads with sub-clinical levels of oppositional defiant disorder (ODD) participated in a 16-week MFG. Child, caregiver, and family outcomes were assessed at baseline, post-treatment, and at 6 months follow-up. Significant decreases in impairment with parents, family members, and peers, and improvements in child self-esteem were found from baseline to follow-up. Caregiver stress increased; no significant changes in depression or perceived social support were found over time. The effectiveness of MFG as a preventive approach and areas of future research are discussed.

Prevalence of Long-COVID Among Low-Income and Marginalized Groups: Evidence From Israel.

Objective: To identify the socioeconomic and demographic factors associated with the prevalence of self-reported long-COVID symptoms. Method: We examined the association between acute-COVID (SARS-CoV-2) and long-COVID symptoms, by a cross-sectional analysis of data obtained on a prospective online-survey, conducted from November to December 2021 on a nationally-representative sample of the Israeli population (N = 2,246). Results: Findings suggest that there is a greater likelihood of experiencing long-COVID symptoms among low-income and among marginalized groups. After controlling for demographic and socioeconomic attributes, those who had moderate/severe acute-COVID were 1.3 (p < 0.05) times more likely to experience a long-term symptom and also reported more long-term symptoms (2.2 symptoms) than those who have not been infected (1.4 symptoms; p < 0.01). Among the low-income group, a larger gap in symptom count was found between those who had moderate/severe acute-COVID (3.3 symptoms) and those who had not been infected (1.8 symptoms, p < 0.05). Conclusion: Our findings highlight the importance of raising awareness of long-COVID among marginalized population groups, and to the therapeutic options available. Such efforts should be tailored and should consider the unique socioeconomic and cultural characteristics, as well as the preexisting low access to healthcare services among these groups.

Predictors of and barriers to receipt of advance premium tax credits.

OBJECTIVES: The Advance Premium Tax Credit (APTC) is designed to remedy lack of health insurance due to cost; however, approximately 30 million Americans remain without health insurance and millions of households leave billions in tax credits unclaimed each year. A prerequisite of APTC is to file one's taxes; however, few studies have examined tax filing and APTC jointly. This study examined the relationship between tax filing and applying for APTC, as well as perceived barriers to and sociodemographic characteristics associated with applying for the APTC. STUDY DESIGN: Descriptive study. METHODS: Researchers surveyed 372 Marketplace-insured members who were eligible for APTC. RESULTS: Most of the sample filed personal taxes in 2019 and planned to file taxes in 2020, yet only 23% applied for the APTC in 2019, and 26.3% were planning to apply in 2020. Most commonly, respondents were not going to apply because they believed they were not eligible (53.5%), they did not know about the APTC (15.8%), and they did not know whether they were eligible (9.9%). Logistic regression modeling found that employment, income, and race were significantly associated with applying for the APTC. CONCLUSIONS: Barriers to applying for the APTC were unrelated to tax filing and were specific to a lack of knowledge about the APTC and eligibility. These results indicate the need to build knowledge and awareness of the APTC and eligibility and to target groups least likely to apply. Implications and future directions are discussed.

Reducing Anxiety and Stress among Youth in a CBT-Based Equine-Assisted Adaptive Riding Program.

Reining in Anxiety (RiA) is a therapeutic program for youth with mild to moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA was developed after a review of the evidence base for youth anxiety, is manualized, and includes five core CBT components: in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. This study extended findings from a prior RCT that examined (1) the feasibility of collecting saliva samples from horses and children to measure stress (cortisol) and relaxation (oxytocin); (2) whether changes in stress and relaxation occurred both during each lesson and over the course of the 10-week intervention for horses and youth; (3) whether changes in anxiety symptoms, emotional regulation, and self-efficacy found in the first trial were comparable; and (4) if fidelity to the program was reliable. Youth participants (n = 39) ages 6-17 with caregiver-identified mild-to-moderate anxiety participated in a ten-week therapeutic intervention (RiA), which combined adaptive riding and components of CBT. Physiological data and self-report measures were taken at weeks one, four, seven, and ten for the youth and horses. Saliva assays assessed cortisol as a physiological marker of stress and anxiety, and oxytocin as a measure of relaxation. Fidelity data were recorded per session. Anxiety, as measured by caregiver self-reporting, significantly decreased from pre- to post-test, while emotional regulation scores increased. No significant changes in self-efficacy from pre- to post-test were observed. Saliva samples obtained from participants before and after riding sessions showed a consistent decrease in cortisol and a significant increase in oxytocin at two of the four timepoints (Week 1 and Week 7), but no overall pre- to post-test changes. Horse saliva data were collected using a modified bit; there were no significant changes in oxytocin or cortisol, suggesting that the horses did not have an increase in stress from the intervention. RiA may be a promising approach for reducing anxiety and stress among youth, as measured both by self-reported and by physiological measures. Collection of salivary assays for both youth and horses is feasible, and the intervention does not increase stress in the horses. Importantly, RiA can be delivered by adaptive/therapeutic horseback riding instructors in naturalistic (e.g., non-clinic-based) settings. As youth anxiety is a growing public health problem, novel interventions, such as RiA, that can be delivered naturalistically may have the potential to reach more youth and thus improve their quality of life. Further research is needed to examine the comparative value of RiA with other animal-assisted interventions and to assess its cost-effectiveness.

Management of depression during the perinatal period: state of the evidence.

BACKGROUND: Perinatal depression (PND) is a prevalent ailment that affects both the woman and her family. Addressing PND in primary health care, such as pediatrics and obstetric care settings, has been proposed as an effective way to identify and treat women. OBJECTIVE: The purpose of this study is to examine best practices for management of PND in obstetric and pediatric settings, as well as investigate the evidence that supports the guidelines. METHODS: Guidelines were identified through a literature search and discussion with experts in the field of perinatal depression, while evidence was examined through a literature search of reviews and thereafter experimental studies. RESULTS: Twenty-five guidelines, across 17 organizations were retained for analysis. Findings suggest that there is little or varied guidance on the management of PND, as well as a lack of specificity. Treatment was the topic most frequently reported, followed by screening. However best practices vary greatly and often contradict one another. Across all areas, there is inadequate or contrasting evidence to support these guidelines. CONCLUSIONS: Although there was consensus on the key steps in the pathway to care, the review revealed lack of consensus across guidelines on specific issues relating to identification and management of depression during the perinatal period. Clinicians may use these recommendations to guide their practice, but they should be aware of the limitations of the evidence supporting these guidelines and remain alert to new evidence. There is a clear need for researchers and policymakers to prioritize this area in order to develop evidence-based guidelines for managing perinatal depression.

Male Caregivers and Engagement in a Family Strengthening Program for Child Disruptive Behavior Disorders.

Awareness and interest in involving male caregivers in child mental health treatment has grown, especially for youth with disruptive behavior disorders like oppositional defiant disorder (ODD). The purpose of this study was to examine the relationship between male caregiver involvement and treatment engagement for child ODD. Children (n = 122) ages 7-11 and their caregivers participated in the 4 Rs 2 Ss Strengthening Families Program for child-onset ODD. Families were compared based on male caregiver presence. Families with a male caregiver were significantly more resourced with respect to income, educational status, and food security. Additionally, they were over three times less likely to drop out of the program than those without a male caregiver. The presence of a male caregiver was associated with increased resources and higher rates of engagement in services than single, female-headed families. Future research is needed to discern the underlying mechanisms of this association.

Public perceptions and the willingness to get vaccinated against COVID-19: Lessons from Israel.

OBJECTIVES: To explore the associations between vaccine hesitancy and demographic and socio-economic characteristics, as well as perspective towards the COVID-19 and its vaccines. METHODS: Data were collected through four online surveys on Israel's representative sample in March (3/2 to 3/7, n = 1517), August (8/10-8/11, n = 925; 8/18-8/22, n = 1054), and September (9/22-9/24; n=1406), 2021. We employ a set of logistic regression models to explore the association between the vaccination action and intentions and the individual-level attributes. RESULTS: We find that individual characteristics, such as age, ethnicity/religiosity, and income, were associated with the vaccination action and intention during the early stage of vaccine distribution. However, most of the discrepancies across demographic groups have disappeared as time passed, and once we limit to those who had not been infected. Lastly, individuals' perspectives toward COVID-19 and its vaccines have prediction power as high as 39% of the vaccination action and intention, higher than their demographic and socio-economic characteristics. IMPLICATIONS: Our findings have the potential to facilitate efforts to increase vaccine uptake by targeting populations, which are the most likely to express hesitancy, and address reported barriers to receipt.

Evaluation of a Modified Bit Device to Obtain Saliva Samples from Horses.

(1) Background: Accounting for the well-being of equine partners is a responsibility of those engaged in Equine-Assisted Services (EAS). Researchers took heed of this call to action by developing an innovative way to collect data to assess the physiological indicators of stress in equine participants. The collection of saliva is considered to be a minimally invasive method of data collection and is typically performed using a cotton swab; however, in equines, the introduction of a foreign object may induce stress; (2) Methods: Researchers used a modified bit to collect pooled saliva in an effort to further reduce stress during the saliva collection process. Additionally, the collection of pooled saliva, via the bit, increases the opportunity to consider additional analyses, such as oxytocin, which is more reliable in pooled saliva than site-specific saliva captured with a swab; (3) Results: A data analysis demonstrated that ample saliva was captured using the modified bit. Observational data supported that the horses demonstrated fewer physical stress signals to the bit than to the swab. Thus, the modified bit is a feasible and valid method for equine salivary sample collection; (4) Conclusions: The results suggest that the modified bit provides a viable method to collect equine saliva and supports national calls to prioritize animal welfare analysis, specifically for horses used within EAS. Future research should enhance methodological rigor, including in the process and timing, thereby contributing to the bit's validation.

From intention to action: A systematic literature review of provider behaviour change-focused interventions in physical health and behavioural health settings.

RATIONALE, AIMS AND OBJECTIVES: It is clear there are significant delays in the uptake of best practices as part of routine care in the healthcare system, yet there is conflicting evidence on how to specifically align provider behaviour with best practices. METHOD: We conducted a review of interventions utilized to change any aspect of provider behaviour. To extend prior research, studies were included in the present review if they had an active intervention targeting behaviour change of providers in health or behavioural-health settings and were published between 2001 and 2020. RESULTS: Of 1547 studies, 44 met inclusion criteria. Of 44 studies identified, 28 studies utilized contextually relevant interventions (eg, tailored to a specific provider population). Twenty six interventions with a contextually relevant approach resulted in provider behaviour change. CONCLUSIONS: Findings are promising for encouraging provider behaviour change when interventions are tailored to be contextually relevant, as both single-component and multifaceted interventions were successful when they were contextually relevant. It is critical to conduct additional research to ensure that providers sustain behaviour changes over a long-term beyond an intervention's implementation and evaluation period.

Examining Organizational Factors Supporting the Adoption and Use of Evidence-Based Interventions.

The purpose of this study was to develop a greater understanding of the factors influencing the adoption of evidence-based interventions in outpatient mental health clinics serving youth. An improved understanding of these factors can potentially improve efforts to ensure effective adoption, implementation, and sustainment of evidence-based interventions, and thus improve treatment for youth in mental health settings. This explanatory cross-sectional study involves secondary data analysis of a longitudinal randomized control intervention trial. The SEM- based model that was tested supported the primary hypothesis that a more supportive organizational climate with greater readiness for change is more likely to improve the chances for the adoption of evidence-based interventions in outpatient mental health clinics serving youths.

Providers' Perspectives on Implementing a Multiple Family Group for Children with Disruptive Behavior.

OBJECTIVES: The adoption of research-supported treatments is contingent upon multiple interactional levels, including provider level factors. Provider-level factors have been shown to be critical to uptake. The purpose of this study is to examine the relationship between sociodemographic factors, attitudes, and perceived barriers/facilitators to implementation through a comparative approach involving practitioners trained to facilitate a multiple family group intervention for children with disruptive behavior. METHODS: Participants included 91 practitioners who participated in an intervention study regarding barriers to adopting an evidence-based practice. Demographic characteristics were collected via a socio-demographic questionnaire. Barriers and facilitators were assessed via open-ended questions as well as a scale, developed by the authors and guided by the Consolidated Framework for Implementation Research that explored provider views regarding the intervention, the systemic and organizational context, experience facilitating groups and involving families in treatment, and feelings toward involving families in treatment. Between group analyses were conducted to examine demographic and characteristic differences of providers by implementation status. Independent samples t-tests for continuous characteristics and chi-square tests for categorical characteristics were used. Responses to open-ended questions were compiled, reviewed, and coded, and frequencies and percentages were calculated. RESULTS: Results demonstrated that providers who implemented the intervention were significantly more likely to have favorable attitudes toward the intervention compared to those who did not implement it. Prior experience facilitating groups was significantly associated with implementation. Common barriers to implementation included ineligible caseloads and feeling unqualified to deliver the intervention. CONCLUSIONS: Further attention on improving recruitment rates and promoting adequate training and supervision is needed.

Outcomes Associated With Adapting a Research-Supported Treatment for Children With Behavior Disorders.

PURPOSE: The aims of this study are to describe an adaptation process of a research-supported treatment (RST) for children with oppositional defiant disorder and to examine provider attitudes toward RSTs prior to and following this process. METHOD: Providers from 14 agencies in New York State delivered the adapted RST, following training. Attitudes toward RSTs were measured by the Evidence-Based Practice Attitude Scale at baseline and posttest. RESULTS: Openness toward RSTs decreased from baseline to posttest. The majority of providers reported modifications to the structure and process of the intervention. DISCUSSION: To improve the uptake and usability of RSTs in practice, future research must further address adaptation processes and their relationships to attitudes toward RSTs.

Getting to the table: Agency characteristics and evidence-based intervention adoption in children's mental health care.

Scaling evidence-based interventions (EBI) for children and families across healthcare systems can expand public health impact. Research has identified EBI adoption determinants. However, less understood are characteristics of agencies that opt in across the stages of adoption. This study examined the relationship between agency (N=69) characteristics (e.g., revenue) and four adoption stages during a large-scale trial of an EBI for children with significant behavioral difficulties and their families. 48 (70%) of agencies demonstrated interest, 28 (41%) scheduled an informational meeting, 20 (29%) received training, and 16 (22%) demonstrated EBI uptake. Analyses indicated no differences in characteristics and initial interest. However, agencies with small-sized revenue had significantly reduced odds at other adoption stages. Implications for strategies to bring EBI access to scale are discussed.

Pilot Study of an Online Parent-Training Course for Disruptive Behavior with Live Remote Coaching for Practitioners.

OBJECTIVE: Many clinicians find it challenging to obtain training in evidence-based interventions, including behavioral parent training, which is considered the front-line treatment for children with disruptive behaviors (Chacko et al., 2017). Workshops, ongoing consultation, and feedback provided in person are effective, yet are rarely feasible for clinicians in the field (Fixsen, Blase, Duda, Naoom, & Van Dyke, 2010). The purpose of the present study was to conduct a preliminary assessment of an online tutorial combined with live remote coaching for training mental health professionals in behavioral parent training. METHOD: Participants in this pretest-posttest open trial were 22 clinicians and graduate students (73% female) from around the United States. RESULTS: The web platform operated successfully, and clinicians found the training to be highly satisfactory. Compared to pre-training, participants demonstrated large improvements in knowledge about disruptive behavior and behavioral parent training and performed significantly better on demonstrations of skill in administering behavioral parent-training components. CONCLUSIONS: An online course combined with live remote coaching is a promising methodology for significantly increasing the number of clinicians trained in evidence-based interventions for disruptive behavior in children. Next steps for evaluation and expansion of this training model are discussed.

Perceived Benefits of a Multiple Family Group for Children with Behavior Problems and their Families.

Multiple family groups (MFG) have shown to have promising results for children with behavioral difficulties. The 4Rs and 2Ss is a curriculum-based multiple family group model for families of children with disruptive behavior disorders, who live in poverty-impacted communities. This study aimed to explore group processes and caregiver perceptions of the benefits of participating in the 4Rs and 2Ss MFG. Caregivers participating in the MFG were asked to complete a 29- item questionnaire which collected information about the perceived benefits of the MFG upon Yalom's therapeutic factors, including group cohesion, universality, interpersonal learning, guidance, catharsis- and self-understanding. Data were analyzed using SPSS 25, and descriptive statistics were performed for each sub-scale. Responses of open-ended questions were reviewed and coded by two of the authors. Thirty-two caregivers completed the survey. Results indicated that the MFG offered multiple benefits that alignwith Yalom's therapeutic factors, such as creating a sense of universality, catharsis, group cohesion, and interpersonal learning. Future research is needed to determine whether such therapeutic factors are associated with changes in child outcomes and family functioning.

Disseminating clinical and fiscal practices across the New York State behavioral healthcare system.

In order to facilitate the adoption of innovative practices in the mental health service system, providers require access to both new information and methodologies, and ongoing training, supervision and consultation. Technical Assistance centers have been proposed as a way to disseminate effective interventions through the provision of resources including information, ongoing training and consultation. The purpose of this study is to describe the New York State Technical Assistance Center's reach across the child public mental health service system and variations in characteristics of training activities, including dosage, content and method of format. Between 2011 and 2015, 460 (92.6%) of all New York State mental health clinics attended a training. The most highly attended events focused on business practices, followed by evidence-based treatments and clinic practices, and trauma-informed care. All were delivered via a webinar format, and were less than one day in duration. The behavioral health service system must be equipped to adapt to changing clinical and business practices in order to provide quality care and remain fiscally viable. New York State's TA center reached the majority of child mental health service providers across the state. Next steps are to closely examine the impact of TA supports upon adoption and sustained use of practices. Implications of these findings and additional future directions are presented.