Expect the unexpected: A qualitative study of the ripple effects of children’s mental health services implementation efforts

BACKGROUND: Strategies to implement evidence-based interventions (EBIs) in children’s mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children’s mental health services, to be used for implementation planning, research, and quality improvement. METHODS: Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. RESULTS: Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one’s own life. CONCLUSIONS: This research advances the field by providing children’s mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children’s mental health implementation strategies for each participant role. Plain Language Summary: This qualitative study of multiple stakeholders in children’s mental health services identifies several possible ripple effects of implementation strategies, opening a new area of study for implementation science. Ripple effects can be positive, negative, or neutral within the full balance of implementation quality and impact. The list of ripple effects will provide implementation scientists, developers, and others with a useful tool during implementation planning and evaluation. This expert-informed methodology can provide a model for other fields for exploring possible ripple effects within implementation science.