Anticipating and evaluating unintended consequences to center ethical implementation in pediatric mental health prevention

PROJECT SUMMARY — RESEARCH PROJECT 3 (RP3) Implementation science holds great potential to increase the reach of effective interventions. However, there has been an underemphasis on prospective planning for and investigating unintended consequences of implementation efforts. This can result in the inadvertent worsening of health outcomes among populations already experiencing disproportionately higher rates of disease burden. Specifically, early mental health screening, identification, and intervention, while promising to improve outcomes for children and families due to the outsized impact on lifespan mental health, has the potential for negative unintended consequences, particularly for children and families struggling with other health and social challenges. Prospectively anticipating and evaluating unintended consequences in pediatric mental health prevention is increasingly recognized as ethically imperative because of the potential harm that could emerge from the implementation of evidence-based approaches. Researching Ethics and Assessment of Unintended Consequences in Healthcare for Mental Health, Earlier (REACH4MHE) seeks to prospectively and concurrently explore and evaluate the unintended consequences that may occur with implementation of evidence-based practices for toddler mental health screening and intervention across all the Mental Health, Earlier (MHE) Center Projects. This work is informed by the Pullmann Compilation of the Ripple Effects of Implementing Children’s Mental Health Services and Rid’s Ethical Evaluation of Risks of Public Health Programs. Foundational to our approach is the inclusion of multiple constituent perspectives across ecological levels to ensure holistic perspectives of unintended consequences resulting from the screening, identification, and intervention for toddler mental health risk. In Aim 1, we will conduct a “pre-mortem" with each MHE Project team, in which we will engage prospective hindsight to identify potential unintended consequences of each project’s implementation. In addition to producing project-specific evaluation plans, these activities will also generate a generalizable methodological approach for future studies. In Aim 2, we will employ a multimethod approach to evaluate ethical issues and unintended consequences across context (caregivers, clinician, organizational [exploratory]) and across MHE projects. This cross-cutting study addresses a prominent limitation of many implementation studies to purposively evaluate and attend to unintended consequences that threaten ethical implementation of early identification and prevention of mental health problems in pediatric primary care. The MHE Center, its individual Projects, and its innovative trial design, provide a unique opportunity to study unintended consequences of implementation across the stages of the mental health risk identification-to-care cascade. This project is significant because it will inform the ideal process through which to engage in collaborative, ethical implementation of early mental health identification, screening, and intervention.