Are Children with Anxiety Disorders Privately Referred to a University Clinic Like Those Referred from the Public Mental Health System?

Managers' Micro-Communities Matter: The Impact of Clinical Supervision Team on Therapist Perception of the Organization

Positive organizational climate - employee perceptions of their work environment and the impact of this environment on well-being and functioning - is associated with desirable organizational and client-level outcomes in mental health organizations. Clinical supervisors are well-positioned to impact organizational climate, as they serve as intermediaries between higher-level administrators who drive the policies and procedures and the therapists impacted by such decisions. This cross-sectional study examined the role of clinical supervisors as drivers of therapist perceptions of organizational climate within supervisory teams. Specifically, the present study investigated: (1) shared perceptions of organizational climate among therapists on the same supervisory team; (2) predictors of therapist climate perceptions. Eighty-six therapists were supervised by 22 supervisors. Indices of interrater agreement and interrater reliability of therapists on the same supervisory team were examined to determine shared or distinct perceptions of organizational climate. Multi-level models were used to examine whether supervisor attitudes towards evidence-based practices and therapist perceptions of supervisor communication predicted perceived organizational climate. Results showed perceptions of organizational cohesion and autonomy were shared among therapists on the same supervisory team and distinct from therapists on different supervisory teams. Therapist perceptions of their supervisor's communication was positively associated with perceptions of organizational cohesion and autonomy. These findings align with emerging evidence that middle managers shape their employees' experience of their work environment through communication strategies. These findings also point to the potential for intervening at lower organizational levels to improve overall organizational climate.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery

OBJECTIVE

This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes.

METHOD

Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery.

RESULTS

At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05).

CONCLUSIONS

Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment

PURPOSE

Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy.

METHOD

This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses.

RESULTS

A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant.

CONCLUSION

Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Training Community Therapists in AIM HI: Individual Family and Neighborhood Factors and Child/Caregiver Outcomes

OBJECTIVE

Publicly funded mental health services play an important role in caring for children with mental health needs, including children with autism spectrum disorder (ASD). This study assessed the associations between individual family- and neighborhood-level sociodemographic factors and baseline family functioning and long-term outcomes when community therapists were trained to deliver An Individualized Mental Health Intervention for ASD (AIM HI).

METHOD

Participants included 144 children with ASD (ages 5 to 13 years; 58.3% Latinx) and their caregivers whose therapists received AIM HI training within a cluster-randomized effectiveness-implementation trial in publicly funded mental health services. Sociodemographic strain (e.g., low income, less education, single-parent status, minoritized status) was coded at the individual family and neighborhood level, and caregivers rated caregiver strain at baseline. Child interfering behaviors and caregiver sense of competence were assessed at baseline and 6-, 12- and 18-months after baseline.

RESULTS

Higher caregiver strain was associated with higher intensity of child behaviors (B = 5.17, p < .001) and lower caregiver sense of competence (B = -6.59, p < 001) at baseline. Child and caregiver outcomes improved over time. Higher caregiver strain (B = 1.50, p < .001) and lower family sociodemographic strain (B = -0.58, p < .01) were associated with less improvements in child behaviors. Lower caregiver strain (B = -2.08, p < .001) and lower neighborhood sociodemographic strain (B = -0.51, p < .01) were associated with greater improvements in caregiver sense of competence.

CONCLUSIONS

Findings corroborate the importance of considering both family and neighborhood context in the community delivery of child-focused EBIs.

TRIAL REGISTRATION

Clinical Trials NCT02416323.

Identifying Youth Problem Profiles and Predicting Remission Following Mental Health Treatment

This study utilized latent profile analysis to categorize youth served by a public mental health setting into homogenous classes. Then, associations between class membership and meeting clinical criteria by the latest assessment were examined. Caregiver responses to the Ohio Scales, Short Form, Problem Severity Scale for 1090 youth completed at entry into this public mental health system were subjected to latent profile analysis. This method classifies youth into categories based on mental health problem profiles, in order to determine the degree to which these groupings are related to later mental health outcomes. The classification of youth cases that emerged was then used to predict clinical remission at or nearest end of treatment, including final Ohio Scales Problem Severity scores and a measure of day-to-day functioning, the Child and Adolescent Functional Assessment Scale (CAFAS). A four-class model was identified as best representing the data, reflecting a relatively low-risk class (63.3% of the sample), an internalizing class (23.2%), a delinquency class (8.8%), and a high-risk class (4.7%). Individuals in the internalizing and high-risk classes had lower likelihoods of achieving problem remission than those in the low-risk and delinquency classes at the time of their last completed Ohio Scales. Additionally, youth assigned to the delinquency and high-risk classes had lower likelihoods of reaching functional impairment remission than those in the internalizing and low-risk classes. Youth membership in a class based on initial problem scores can be utilized to predict clinical remission over the course of treatment in public mental health care. Such class-based predictions support other methods of predicting outcomes and can be used by clinicians to develop more informed treatment plans and to adjust treatment based on such classifications.

A Second and Third Look at FIRST: Testing Adaptations of A Principle-Guided Youth Psychotherapy

Objective: We examined the acceptability, integrity, and symptom trajectories associated with FIRST, a principle-guided treatment for youth internalizing and externalizing problems designed to support efficient uptake and implementation.Method: We conducted two open trials of an adapted FIRST, focusing on uptake and implementation by novice trainees in a university-affiliated clinic, limiting treatment duration to six sessions, and benchmarking findings against a 2017 FIRST trial with community therapists. In Study 1, trainees received a two-day training and weekly two-hour supervision (N = 22 youths, ages 7-17, 50% female, 54.54% Caucasian, 4.55% Latinx). In Study 2, trainees received a one-day training and weekly one-hour supervision, delivering the six-session FIRST in a predetermined sequence (N = 26 youths, ages 11-17, 42.31% female, 65.38% Caucasian, 7.69% Latinx). In Study 3, the original study therapists - now practitioners - evaluated FIRST's effectiveness and implementation difficulty, and reported their own post-study FIRST use.Results: Acceptability (treatment completion, session attendance, caregiver participation) and integrity (adherence, competence) were comparable across Study 1, Study 2 and the 2017 trial. Improvement effect sizes across ten outcome measures were in the large range in all three trials: M ES = 1.10 in the 2017 trial, 0.83 in Study 1, and 0.81 in Study 2. Study 3 showed high effectiveness ratings, low difficulty ratings, and continued use of FIRST by a majority of clinicians.Conclusions: Across two open trials and a follow-up survey, FIRST showed evidence of acceptability and integrity, with youth symptom reduction comparable to that in prior research.

Integrating Advocacy for Marginalized Children and Families Into Evidence-Based Care During COVID-19: Clinical Vignettes

The novel coronavirus (COVID-19) has disproportionately impacted the health and socioeconomic outcomes for low-income populations, people of color, and immigrant children and families in the United States. As inequities in resources (i.e., food, internet, housing), health care, and education increased for marginalized families as a result of COVID-19, child-focused clinicians had to broaden their professional scope and implement new advocacy efforts. The current paper uses clinical vignettes taken from a New York State Office of Mental Health-licensed child and adolescent outpatient clinic in the Bronx, New York. The vignettes highlight the social inequities that impacted marginalized children and families during the pandemic, as well as the clinical team's response through the integration of evidence-base practice and advocacy. Implications for practice with vulnerable populations as the COVID-19 pandemic persists are discussed.

Application of Evidence-Based Treatment in Community Mental Health Settings: Examining EBT Delivery Duration and Client Discharge

Characterizing community mental health (CMH) treatment duration and discharge is an important step toward understanding how to better meet client needs. This report describes patterns of treatment duration and discharge among clinicians participating in a state-funded evidence-based treatment (EBT) training initiative. After training and consultation, clinicians (N = 376) reported on treatment duration and discharge for their "most complete case." On average, clinicians delivered 12.4 sessions (SD = 5.1) of the treatment. After completing treatment, half of clinicians (58.7%) continued with regularly scheduled therapy, either using EBT elements or switching to supportive therapy. Clinicians who continued with regularly scheduled therapy delivered treatment in approximately the same number of sessions. Results revealed that CMH clinicians often do not discontinue therapy after completing a treatment protocol. These findings suggest it may be essential to better understand clinician decision-making around applying EBTs to their caseloads.

Interpretation biases and depressive symptoms among anxiety-disordered children: The role of individual differences in respiratory sinus arrhythmia

Individual differences in interpretation biases-the tendency to interpret ambiguous stimuli as threatening-partially explain the presence of comorbid depressive symptoms among anxious youth. Increasing efforts have examined physiological processes that influence the association between interpretation biases and depressive symptoms in this population, and potential gender differences in this relationship. This study examined the moderating role of respiratory sinus arrhythmia (RSA) suppression (i.e., decrease from baseline)-an index of parasympathetic nervous system reactivity-in the association between interpretation biases and depressive symptoms in clinically anxious youth. One-hundred-and-five clinically anxious children (Mage  = 10.09 years, SD = 1.22; 56.7% female; 61.9% racial/ethnic minority) completed measures of self-reported and behaviorally indexed interpretation biases, reported anxiety/depression symptom severity, and participated in a speech task. RSA suppression during the task moderated the association between interpretation biases and depressive symptom severity in the total sample. Separate exploratory moderation analyses were conducted among girls and boys. Among girls, RSA suppression moderated the association between behaviorally indexed interpretation biases and depressive symptoms, and marginally moderated (p = .067) the association between self-reported interpretation biases and depressive symptoms. Among boys, RSA suppression was not a significant moderator. These findings may help identify clinically anxious youth most at-risk for comorbid depressive symptoms.

Fearful Temperament and Child Social Anxiety Symptoms: Clarifying the Influence of Maternal Punitive Responses

Fearful temperament-the tendency to exhibit apprehension and/or avoidance in novel situations-is a well-established risk factor for childhood anxiety in general, and social anxiety in particular. Yet, there is little understanding of parent emotion socialization strategies that influence the association between fearful temperament and child social anxiety symptoms. The present investigation addresses this gap in the literature by examining maternal punitive responses to clinically anxious children's negative emotions as a moderator of the covariance between fearful temperament and social anxiety symptom severity. Clinically anxious children ages 8-12 years (N = 105; 57.1% female; 61.9% racial/ethnic minority) and their mothers completed measures assessing child fearful temperament, maternal punitive emotion socialization responses, and child social anxiety symptoms. Children also participated in an anxiety-provoking speech task during which manifest social anxiety was coded by trained observers. Children's fearful temperament coupled with greater maternal punitive responses to children's negative emotions was associated with lower child-reported social anxiety symptoms. Models predicting manifest social anxiety were not significant. Maternal punitive responses to children's negative emotions may encourage clinically anxious youth to approach feared situations and therefore result in lower anxiety. Yet, the potentially negative effects of punitive responses on other aspects of anxious children's socioemotional development warrant scientific attention. Future research should examine the phenomenology of punitive parental responses among parents of anxious youth to better understand their effects on child behavior.

Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings

Most efforts to assess treatment integrity-the degree to which a treatment is delivered as intended-have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.

Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India

This paper documents the collaborative design of a mental health intervention for adolescents in India with anxiety, depression, or anger-related concerns. The process was characterized by three phases of formative activities: (1) an intensive review of the service context, (2) selection of an overall design strategy (e.g., whether to choose existing evidence-based treatments or build new treatments in context), and (3) a period of prototyping, testing, and refining. Each phase resulted in specific outputs, which were, respectively, (1) a detailed articulation of values and preferences (setting expectations for what the ideal protocol should be), (2) a set of build parameters representing a blueprint that managed strategic compromises for this context, and (3) a working protocol. We outline the steps of this design process, summarize data from an open-trial clinical case series, and illustrate the resulting working protocol, which will be tested in a future larger trial. We conclude with insights and observations likely to be relevant to protocol design activity in a variety of contexts, most particularly those in low-and-middle-income countries such as India.

A Mixed-Method Analysis on the Impacts of a System-Driven Implementation of Multiple Child Evidence-Based Practices on Community Mental Health Providers

Initiatives to scale up evidence-based practices (EBPs) in routine care are likely to have myriad impacts on community providers, but these impacts have not yet been examined in depth. This is especially true within the context of simultaneous implementation of multiple evidence-based practices. The aim of this study was to characterize the multifaceted impacts on community mental health therapists within a system-driven implementation of multiple EBPs for youth and families. Semistructured interview and survey data were gathered from 60 therapists at 11 agencies contracted with the Los Angeles County Department of Mental Health to deliver EBPs within the Prevention and Early Intervention initiative. Therapists' accounts of impacts varied, and were either predominately negative, predominantly positive, or mixed-valence. Mixed-methods analyses using Kruskal-Wallis tests showed therapist valence groups varied on mean levels of self-reported burnout on surveys. Themes from qualitative data revealed several favorable (e.g., increased EBP knowledge, structure) and unfavorable (e.g., distress, feeling constrained by EBPs) impacts of county-contracted EBP implementation. These findings inform the development and implementation of future system-driven EBP initiatives that consider therapist perspective to optimize positive impacts and minimize negative impacts on therapists.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov .

Emergent life events in the delivery of a caregiver-mediated evidence-based intervention for children with autism spectrum disorder in publicly funded mental health services

LAY ABSTRACT

Mental health clinicians often report significant challenges when delivering evidence-based interventions (EBI) in community settings, particularly when unexpected client stressors (or emergent life events; ELEs) interfere with the therapy process. The current study sought to extend the study of ELEs to children with Autism Spectrum Disorder (ASD) by examining the occurrence and impact of ELEs in the context of a collaborative, caregiver-mediated intervention for reducing challenging behaviors in children with ASD. This intervention was An Individualized Mental Health Intervention for children with ASD (referred to as AIM HI). Participants included 38 clinicians and child clients who were enrolled in a community effectiveness trial of AIM HI. Video recordings of 100 therapy sessions were coded for caregiver-reported ELEs and also how well clinicians adhered to the AIM HI protocol. Results indicated that mild to severe ELEs were reported in 36% of therapy sessions, and were reported for 58% of children at some point during the intervention. Children who had a greater number of diagnoses (in addition to the autism diagnosis) tended to have more ELEs. In addition, clinicians with less years of experience tended to have sessions with more ELEs. There was no significant link between ELEs and how well clinicians adhered to the AIM HI protocol. Findings offer implications for the implementation of EBI, particularly the importance of incorporating clinician training in addressing complex presentations and crises in the context of EBIs.

Characterizing the heterogeneity of clinician practice use in community mental health using latent profile analysis

BACKGROUND

The behavioral health service provider population is highly heterogeneous. However, it is rarely treated as such within evidence-based practice implementation efforts. This study aimed to evaluate, as a proof of concept, the utility of latent profile analysis to identify distinct profiles of clinician practices in a large sample of youth-serving community mental health clinicians. This study also aimed to identify predictors of profile membership to inform implementation efforts.

METHODS

Participants were 484 practicing clinicians (79.4% female, 45.7% White, M age = 37.1 years). As part of a larger survey, clinicians reported on their use of cognitive, behavioral, family, and psychodynamic treatment techniques with a representative client on their caseload. Latent profile analysis was used to determine the presence of clinician practice profiles. Multilevel multinomial logistic regressions examined predictors of profile membership.

RESULTS

Latent profile analysis indicated a 4-profile solution best fit the data, with clinicians who: 1) used generally low levels of all examined techniques and preferred cognitive techniques (Low Eclectics, 16%), 2) delivered moderate levels of all techniques (Moderate Eclectics, 53%), 3) demonstrated preference for use of family techniques (Family Preferred, 11%), and 4) used high levels of all techniques (Super Users, 20%). Clinician discipline (e.g., social work), education, and years of experience predicted profile membership.

CONCLUSIONS

Findings from this proof of concept study underscore the utility of latent profile analysis to characterize the complex and heterogeneous makeup of community mental health. Results extend prior work highlighting the eclectic nature of community mental health practice. Predictor analyses underscore the important influence of clinician background characteristics on practice use.

Unintended Consequences of Evidence-Based Treatment Policy Reform: Is Implementation the Goal or the Strategy for Higher Quality Care?

This study examined patterns of evidence-based treatment (EBT) delivery following a county-wide EBT reform initiative. Data were gathered from 60 youth and their 21 providers, who were instructed to deliver therapy as they normally would under the EBT initiative. Results showed limited applicability of county-supported EBTs to this service sample, and that most youth did not receive traditional delivery of EBTs. Findings suggest that it may be unrealistic to expect providers to deliver EBTs with fidelity with all clients, and that EBT implementation may be best thought of as a strategy for improving mental health services rather than a goal.

Group- versus Parent-Involvement CBT for Childhood Anxiety Disorders: Treatment Specificity and Long-term Recovery Mediation

Objective

Treatment specificity and long-term recovery mediation of peer-involvement group cognitive behavioral therapy (GCBT) and parent-involvement CBT (PCBT) were investigated for youth anxiety disorders.

Method

240 youths with primary anxiety diagnoses participated in a randomized controlled efficacy trial. Youth anxiety and peer variables/mediators (positive peer-youth relationships; social skills), and parent variables/mediators (psychological control; negative parent-youth relationships) were assessed.

Results

At posttreatment and 12-month follow up, positive peer-youth relationships were significantly higher in GCBT than PCBT (specificity). At posttreatment, not follow up, parental psychological control was significantly lower in PCBT than GCBT (specificity). Parental psychological control and positive peer-youth relationships were putative mediators. The two CBTs produced similar anxiety reductions through different mechanisms.

Conclusions

CBT targets show specificity and mediation, providing insight into specific mechanisms through which GCBT and PCBT bring about anxiety reduction and guidance for streamlining these CBTs in practice.

Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings

BACKGROUND

The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families.

OBJECTIVE

The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists' self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children's mental health services.

METHOD

One hundred and three therapists reported on two types of engagement challenges-Limited Client Engagement and Expressed Client Concerns-in 702 sessions with 274 clients.

RESULTS

Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. Both types of engagement challenges were negatively associated with therapists' report of their ability to carry out intended activities in the same session.

CONCLUSIONS

Findings suggest that therapists may benefit from learning strategies to address these two distinct types of engagement challenges encountered in implementation of EBPs with diverse families in community settings.

"Teaching Moments" in Psychotherapy: Addressing Emergent Life Events Using Strategies From a Modular Evidence-Based Treatment

Emergent life events (ELEs) are unexpected, acute client stressors reported in psychotherapy sessions that are associated with reduced evidence-based treatment (EBT) integrity and client progress. As a potential solution, this study examined the extent to which ELEs could be appropriately addressed using existing EBT strategies. Participants were 34 low-income youth (ages 5-15, 50% male, 85% Latino) seen by 18 therapy providers in the modular EBT condition (MATCH) of a community effectiveness trial. MATCH experts rated descriptions of 75 ELEs from therapy sessions on how well they might be addressed clinically by any of MATCH's 33 strategies for youth anxiety, depression, trauma, or conduct problems (i.e., "addressability"). MATCH-expert ratings were compared with observationally coded provider responses to ELEs. Results revealed that when assuming the presence of youth and caregiver in session, two-thirds of ELEs were identified as fully addressable and nearly all ELEs (96%) were partially addressable. ELEs related to family issues were most common but least likely to be addressable. Problem Solving and Relaxation skills could address the greatest percentage (87%) of ELEs. The most common supplemental content not explicitly prescribed in MATCH, but identified as necessary to fully address ELEs, was "assessing and empathic listening." Provider responses were often incongruent with MATCH-expert raters regarding which strategies to use for which ELEs. In summary, most ELEs reported in a diverse community sample could be theoretically harnessed as "teaching moments" for skills within an existing, multi-problem EBT. However, providers may benefit from development of a structured resource to guide them in choosing the most effective response when these unexpected events arise.

Predictors of long-term outcome of CBT for youth with anxiety disorders treated in community clinics

Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11-21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2-5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.

Community-Based Providers' Selection of Practices for Children and Adolescents With Comorbid Mental Health Problems

The goal of this study is to explore providers' patterns of implementation by investigating how community mental health providers selected therapy practice modules from a flexible, modular evidence-based treatment working with youths with comorbid mental health problems. Data were obtained from 57 youths, 5-15 years old, presenting with anxiety, depressive, and/or conduct problems and their 27 providers during their participation in an effectiveness trial involving a modular evidence-based treatment. Although all youths evidenced clinically elevated symptomatology in at least two problem areas, providers targeted youths' comorbid problems with only about half of their study cases. Practice modules indicated for youths' comorbid problems were typically used less frequently and with less depth relative to practice modules indicated for youths' principal clinical problem and were often transdiagnostic in nature (i.e., designed to target more than one problem area). To determine whether providers' decisions to target youths' comorbid problems were systematic, multilevel, logistic regression analyses were conducted and revealed that youths' pretreatment characteristics and time in therapy influenced providers' patterns of module selection. Providers tend to use, but not exploit, the flexibility allowed by modular EBTs and to focus treatment on youths' principal presenting problem. In addition, providers appear to make these practice choices in a systematic and rational manner, and whether and which choices are associated with improved outcomes is an important area of future study.

Emergent Life Events: An In-Depth Investigation of Characteristics and Provider Responses during Youth Evidence-Based Treatment

Emergent life events (ELEs), or acute client stressors disclosed within psychotherapy sessions, are not addressed by many evidence-based psychosocial treatments (EBTs). Preliminary provider-report studies suggest that ELEs may interfere with effective EBT implementation. The present study offers a detailed, observational examination of ELEs and their impact on EBT within therapy sessions. Data were observationally coded from 274 sessions with 55 primarily low-income, Latino youth clients (58% male, ages 5-15) in the modular EBT condition (Modular Approach to Therapy for Children [MATCH]) of the Child STEPs California trial. The ELE Coding System-Revised was used to measure ELEs, their characteristics, and provider responses to ELEs, including provider adherence to MATCH. Interrater reliability was generally high. At least one ELE was identified in 13% of randomly selected sessions. ELEs ranged widely in content, and their characteristics did not cluster together. Providers responded more frequently to ELEs with non-EBT content (e.g., information gathering, empathy) than EBT content; use of the ELE as a "teaching moment" for EBT content was the least common response (40% of ELEs). Multilevel regression analyses revealed that compared to sessions without an ELE, ELE sessions were significantly associated with reduced provider adherence to MATCH. Within ELE sessions, higher client distress when discussing the ELE was associated with reduced provider adherence to MATCH, but only when ELE severity was high. Beyond provider report, observational measures indicate that ELEs are prevalent and unpredictable in community settings and disrupt EBT delivery. Findings can inform the development of structured ELE management procedures to enhance existing EBTs.

Predictors of Burnout among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children's Mental Health

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.

Benchmarking Treatment Adherence and Therapist Competence in Individual Cognitive-Behavioral Treatment for Youth Anxiety Disorders

Evidence-based treatments (EBTs) for youth are typically developed and established through studies in research settings designed to ensure treatment integrity, that is, protocol adherence and competence by therapists. An important question for implementation science is how well integrity is maintained when these EBTs are delivered in community settings. The present study investigated whether the integrity achieved by therapists in community settings achieved a benchmark set by therapists in a research setting when they delivered the same EBT-an individual cognitive-behavioral treatment (ICBT) for youth anxiety. Therapists (N = 29; 68.97% White; 13.79% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.35% White; 52.94% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols were the same across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess ICBT adherence and competence. Both adherence and competence were higher in the research setting. Group differences in competence were consistent across treatment, but differences in adherence were most pronounced when treatment shifted to exposure, widely viewed as the most critical component of ICBT. When using the benchmarks from the research setting, therapists from the community settings fell short for indices of adherence and competence. However, given differences between therapists and clients, as well as the fact that treatment outcomes were similar across settings, our findings raise questions about whether it is appropriate to use treatment integrity benchmarks from research settings for community.

Prevalence and Clinical Differences of Suicidal Thoughts and Behaviors in a Community Sample of Youth Receiving Cognitive-Behavioral Therapy for Anxiety

This study examined the incidence of suicidal thoughts and behaviors in youth with anxiety before initiating cognitive behavioral therapy, as well as the emergence of suicidal thoughts and behaviors during treatment. Overall, 30% of youth experienced suicidal thoughts and behaviors. Prior to treatment, 24% reported suicidal thoughts and behaviors, and 13.1% endorsed suicidal thoughts and behaviors during treatment. More than half who endorsed suicidal thoughts and behaviors during treatment were newly identified cases not detected prior to treatment. Disagreement among parent- and child-report measures of suicidality was found at baseline. Youth who experienced suicidal thoughts and behaviors had higher levels of loneliness, depressive symptoms, overt peer victimization, functional impairment, and externalizing symptoms. Findings suggest that the assessment of suicidality at a single time-point and from one informant is not sufficient to identify at-risk youth. Ongoing assessment of suicidal risk during treatment is important in this population.

Managing In-Session "Surprises:" Provider Responses to Emergent Life Events during Evidence-Based Treatment Implementation

This study aimed to: (1) pilot a psychotherapy coding system for provider responses to emergent life events (ELEs; unexpected events that have a significant negative impact on the client), (2) examine the impact of ELEs on evidence-based treatment (EBT) delivery in community settings. Raters coded 30 randomly-sampled EBT session recordings with and without reported ELEs. Inter-rater reliability and validity for the system were generally high. When an ELE occurred, providers were significantly less likely to deliver the EBT, and when they did, they rarely linked the EBT to the event. Findings highlight the potential for ELEs to disrupt EBT implementation.

Development and Initial Psychometrics for a Therapist Competence Instrument for CBT for Youth Anxiety

Therapist competence is an important component of treatment integrity. This article reports on the development and initial psychometric assessment of the Cognitive-Behavioral Treatment for Anxiety in Youth Competence Scale (CBAY-C), an observational instrument designed to capture therapist limited-domain competence (i.e., competence in the delivery of core interventions and delivery methods found in a specific psychosocial treatment program) in the delivery of the core practice elements in individual cognitive-behavioral treatment (ICBT) for youth anxiety. Treatment sessions (N = 744) from 68 youth participants (M age = 10.60 years, SD = 2.03; 82.3% Caucasian; 52.9% male) of the same ICBT program for youth anxiety from (a) an efficacy study and (b) an effectiveness study were independently scored by 4 coders using observational instruments designed to assess therapist competence, treatment adherence, treatment differentiation, alliance, and client involvement. Interrater reliability-intraclass correlation coefficients (2,2)-for the item scores averaged 0.69 (SD = 0.11). The CBAY-C item, scale, and subscale (Skills, Exposure) scores showed evidence of validity via associations with observational instruments of treatment adherence to ICBT for youth anxiety, theory-based domains (cognitive-behavioral treatment, psychodynamic, family, client centered), alliance, and client involvement. Important to note, although the CBAY-C scale, subscale, and item scores did overlap with a corresponding observational treatment adherence instrument independently rated by coders, the degree of overlap was moderate, indicating that the CBAY-C assesses a distinct component of treatment integrity. Applications of the instrument and future research directions discussed include the measurement of treatment integrity and testing integrity-outcome relations.

Integrity of evidence-based practice: are providers modifying practice content or practice sequencing?

This study examined patterns of evidence-based treatment (EBT) implementation within community settings by evaluating integrity along separate dimensions of practice content (PC; a session included the prescribed procedure) and practice sequencing (a session occurred in the prescribed sequence) within a recent randomized effectiveness trial. We measured whether sessions showed integrity to PC and to flexible or linear practice sequences. Findings revealed that providers tended to incorporate content from the EBT protocol in most treatment sessions, but that the sequencing of the sessions was often modified, suggesting that providers are amenable to evidence-based procedures, but not necessarily their prescribed arrangement.

Choices in Treatment Integrity:Considering the Protocol and Consultant Recommendations in Child and Adolescent Therapy

Codifying a complex treatment intervention into a manual necessarily involves simplifying procedures, possibly resulting in developer and expert adaptations that align with but are not fully consistent with the manualized content. This study evaluated the integrity of an evidence-based treatment to two information sources (i.e., an expert consultant and the treatment manual) within youth community mental health settings. Consultant recommendations were compared with manual-prescribed therapy procedures, which identified instances of agreement between the sources as well as consultant adaptations. To determine clinicians' integrity to each source, clinician-reported therapy procedures were compared with consultant recommendations and manual prescriptions. Participants consisted of 30 clinicians, five consultants, and 78 youths (53% male; M age = 9.73 years, SD = 2.84; 81% Latino). Findings indicated that consultants generally recommended content from the manual but also made frequent adaptations that involved changing the sequence or problem focus of practices and adding additional content. Clinicians followed both information sources in a majority of their sessions when these sources agreed but were more likely to follow only one or neither source when they disagreed. Findings suggest that consultants often make adaptations to the manual and that clinicians are more likely to employ recommendations from the manual and/or consultant when the information sources are in agreement. Although it is as yet unclear whether consultant recommendations are effective when they differ from the prescriptions of the manual, results from this study indicate that information sources that supplement treatment manuals may benefit clinical decision making.

[Modular psychotherapy with children and adolescents]

The implementation of evidence-based psychotherapy with children and adolescents has been limited so far. This is mainly due to the fact that patients in service settings tend to have higher rates of comorbidities and more frequently changing therapy needs than those in research settings. Thus, modular psychotherapies are promising, as they allow the treatment protocol to be adapted to patients’ individual needs. Because no review on modular psychotherapy for children and adolescents exists, we conducted a systematic literature research. The results of the 15 randomized controlled trials identified demonstrate that modular psychotherapy is associated with significant reductions in symptom levels as well as with higher rates of diagnostic remission compared to control conditions. Because of the lack of evidence, future studies should investigate the incremental efficacy of modular approaches and test the validity of underlying theoretical models as well as of decision flowcharts. Modular psychotherapy approaches have the potential to personalize evidence-based interventions for children and adolescents across various therapeutical traditions, and to facilitate their implementation into clinical practice.

The role of setting versus treatment type in alliance within youth therapy

OBJECTIVE

Does the strength of the youth-therapist alliance differ across treatment settings or treatment type? We examined these questions in the context of youth therapy.

METHOD

Eighty-nine youths (M age = 10.56, SD = 1.99; 63.70% Caucasian; 52.80% male) diagnosed with an anxiety disorder received (a) manual-based individual cognitive-behavioral therapy (ICBT) in a research setting, (b) manual-based ICBT in practice settings, or (c) nonmanualized usual care (UC) in practice settings. Coders, using the Therapy Process Observational Coding System-Alliance scale, rated 865 sessions. Youth completed the Therapeutic Alliance Scale for Children at posttreatment.

RESULTS

Youth who received ICBT in a research setting had significantly higher observer-rated alliance than youth who received either therapy delivered in practice settings. In practice settings, youth who received ICBT had significantly stronger observer-rated alliance early in treatment than youth in UC, but this difference was not observed at the end of treatment. Similarly, youth-report alliance at posttreatment was significantly higher in ICBT in the research setting, and there was no difference between ICBT and UC delivered in practice settings. Alliance differences largely held when controlling for youth characteristics; however, differences early in treatment between the ICBT groups were no longer statistically significant when controlling for anxiety severity or primary anxiety diagnosis.

CONCLUSIONS

Our findings suggest that (a) the alliance may be stronger in research settings, and (b) treatment manuals do not undermine alliance. Future research is required to help pinpoint whether other youth, therapist, or setting factors contribute to the lower alliance seen in practice settings.

Predictors of treatment outcome in an effectiveness trial of cognitive behavioral therapy for children with anxiety disorders

A substantial number of children with anxiety disorders do not improve following cognitive behavioral therapy (CBT). Recent effectiveness studies have found poorer outcome for CBT programs than what is typically found in efficacy studies. The present study examined predictors of treatment outcome among 181 children (aged 8-15 years), with separation anxiety, social phobia, or generalized anxiety disorder, who participated in a randomized, controlled effectiveness trial of a 10-session CBT program in community clinics. Potential predictors included baseline demographic, child, and parent factors. Outcomes were as follows: a) remission from all inclusion anxiety disorders; b) remission from the primary anxiety disorder; and c) child- and parent-rated reduction of anxiety symptoms at post-treatment and at 1-year follow-up. The most consistent findings across outcome measures and informants were that child-rated anxiety symptoms, functional impairment, a primary diagnosis of social phobia or separation anxiety disorder, and parent internalizing symptoms predicted poorer outcome at post-treatment. Child-rated anxiety symptoms, lower family social class, lower pretreatment child motivation, and parent internalizing symptoms predicted poorer outcome at 1-year follow-up. These results suggest that anxious children with more severe problems, and children of parents with elevated internalizing symptom levels, may be in need of modified, additional, or alternative interventions to achieve a positive treatment outcome.

Predictors of dropout from community clinic child CBT for anxiety disorders

The aim was to investigate predictors of treatment dropout among 182 children (aged 8-15 years) participating in an effectiveness trial of manual-based 10-session individual and group cognitive behavior therapy (CBT) for anxiety disorders in community clinics. The dropout rate was 14.4%, with no significant difference between the two treatment conditions. We examined predictors for overall dropout (n=26), early (≤session 4, n=15), and late dropout (≥session 5, n=11). Overall dropout was predicted by low child and parent rated treatment credibility, and high parent self-rated internalizing symptoms. Low child rated treatment credibility predicted both early and late dropout. High parent self-rated internalizing symptoms predicted early dropout, whereas low parent rated treatment credibility predicted late dropout. These results highlight the importance of addressing treatment credibility, and to offer support for parents with internalizing symptoms, to help children and families remain in treatment.

Monitoring Client Progress and Feedback in School-Based Mental Health

Research in children's mental health has suggested that emotional and behavioral problems in are inextricably tied to academic difficulties. However, evidence-based programs implemented in school-based mental health tend to focus primarily on treatment practices, with less explicit emphasis on components of evidence-based assessment (EBA), such as progress monitoring and feedback. The current paper describes two studies that incorporated standardized assessment and progress monitoring/feedback into school-based mental health programs. Barriers to implementation are identified, recommendations for clinicians implementing EBA in the school setting are provided, and examples of mental health and academic indicators are discussed.

Service Use Findings from the Child STEPs Effectiveness Trial: Additional Support for Modular Designs

This study expands upon the Chorpita et al. (J Consult Clin Psychol 81:999-1009, 2013) findings by examining the impact of treatment protocol on youths' service utilization up to 2 years after starting an episode of: standard manualized treatment (Standard); modular treatment (Modular); or usual care (UC). Results showed that youths who received Modular accessed fewer service settings at their one-year follow-up relative to youths who received Standard or UC. Findings suggest that modular treatment may offer an advantage over standardized treatment manuals and UC in terms of sustained clinical benefits, and highlight the importance of treatment design considerations for service systems.

Acting Locally and Globally: Dissemination and Implementation Around the World and Next Door

Murray et al. (this issue) present a fascinating account of their international dissemination and implementation (D&I) research focused on training therapists in Thailand and Iraq to provide a modular treatment approach called Common Elements Treatment Approach to youth. In this commentary, we use Murray et al. as a springboard to discuss a few general conclusions about the current direction of D&I research. Specifically, we reflect on current D&I models, highlighting their ecological focus and their emphasis on stakeholder involvement. Next, we discuss the central importance of implementation supports such as treatment programs, training approaches, assessment and outcome monitoring tools, and organizational interventions. We conclude with a consideration of how D&I work that aims to adapt implementation supports for local needs represent a key path to our goal of sustainability.

An analysis of stakeholder views on children's mental health services

The purpose was to examine the perspectives of mental health stakeholders as a means to guide the adaptation of evidence-based treatments. The Mental Health System Ecological (MHSE) model was used to organize therapist, administrator, and parent perspectives gathered using qualitative methods. The MHSE model posits the influences of client-level, provider-level, intervention-specific, service delivery, organizational, and service system characteristics on implementation. Focus groups and interviews were conducted with community mental health stakeholders and included parents, therapists, and administrators (N = 21). Participants included 11 primarily Caucasian (90.48%) female participants, ranging in ages between 31 and 57 years. Data were analyzed according to the MHSE model. Frequency counts were tabulated for each theme and stakeholder group differences were determined using the Mann-Whitney test. Stakeholder groups mentioned needs at each level of the MHSE model. Stakeholder group differences most notably emerged with child and family themes, which included complexity of mental health issues, parenting differences, and family stressors. Stakeholders identified challenges for optimal mental health services for children across multiple levels of an ecological model. Implications of the findings are discussed, including the continued relevance of adapting mental health interventions by increasing their flexible application across multiple target problems and the promise of partnership approaches.

Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform children's mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of "common elements" of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.

Using modular psychotherapy in school mental health: provider perspectives on intervention-setting fit

The "fit" or appropriateness of well-researched interventions within usual care contexts is among the most commonly cited, but infrequently researched, factors in the successful implementation of new practices. The current study was initiated to address two exploratory research questions: How do clinicians describe their current school mental health service delivery context? and How do clinicians describe the fit between modular psychotherapy and multiple levels of the school mental health service delivery context? Following a year-long training and consultation program in an evidence-based, modular approach to psychotherapy, semistructured qualitative interviews were conducted with 17 school-based mental health providers to evaluate their perspectives on the appropriateness of implementing the approach within a system of school-based health centers. Interviews were transcribed and coded for themes using conventional and directed content analysis. Findings identified key elements of the school mental health context including characteristics of the clinicians, their practices, the school context, and the service recipients. Specific evaluation of intervention-setting appropriateness elicited many comments about both practical and value-based (e.g., cultural considerations) aspects at the clinician and client levels but fewer comments at the school or organizational levels. Results suggest that a modular approach may fit well with the school mental health service context, especially along practical aspects of appropriateness. Future research focused on the development of methods for routinely assessing appropriateness at different stages of the implementation process is recommended.

MAPping Los Angeles County: taking an evidence-informed model of mental health care to scale

We describe the scaling up of an evidence-informed model of care, Managing and Adapting Practice (MAP) in Los Angeles County, California. MAP complemented an array of evidence-based programs selected by the county as part of a large system reform effort designed to improve care for children and adolescents. In addition, we discuss the MAP model for training therapists and present data both on how the training model performed and on the outcomes of youths treated by therapists trained in MAP. We examined the success of two different training pathways for MAP therapists: (a) national training model and (b) MAP agency supervisor model (i.e., train the trainer). We also examined utilization of MAP and outcomes of clients served by MAP. Both the national training and MAP agency supervisor model were successful in producing MAP therapists in a timely fashion and with acceptable competency scores. Furthermore, a large number of clients were receiving MAP services. Finally, outcomes for youth treated with MAP were strong, with effect sizes ranging from .59 to .80 on the Youth Outcome Questionnaire. These data support the notion that scaling up a mental health services approach in a system can be achieved through a strong and broad partnership among relevant stakeholders, can involve a train-the-trainer model, and can result in strong outcomes for clients.

Making a Case for Treatment Integrity as a Psychosocial Treatment Quality Indicator for Youth Mental Health Care

Measures of treatment integrity are needed to advance clinical research in general and are viewed as particularly relevant for dissemination and implementation research. Although some efforts to develop such measures are underway, a conceptual and methodological framework will help guide these efforts. The purpose of this article is to demonstrate how frameworks adapted from the psychosocial treatment, therapy process, healthcare, and business literatures can be used to address this gap. We propose that components of treatment integrity (i.e., adherence, differentiation, competence, alliance, client involvement) pulled from the treatment technology and process literatures can be used as quality indicators of treatment implementation and thereby guide quality improvement efforts in practice settings. Further, we discuss how treatment integrity indices can be used in feedback systems that utilize benchmarking to expedite the process of translating evidence-based practices to service settings.

Evidence-based youth psychotherapy in the mental health ecosystem

Five decades of randomized trials research have produced dozens of evidence-based psychotherapies (EBPs) for youths. The EBPs produce respectable effects in traditional efficacy trials, but the effects shrink markedly when EBPs are tested in practice contexts with clinically referred youths and compared to usual clinical care. We considered why this might be the case. We examined relevant research literature and drew examples from our own research in practice settings. One reason for the falloff in EBP effects may be that so little youth treatment research has been done in the context of everyday practice. Researchers may have missed opportunities to learn how to make EBPs work well in the actual youth mental health ecosystem, in which so many real-world factors are at play that cannot be controlled experimentally. We sketch components and characteristics of that ecosystem, including clinically referred youths, their caregivers and families, the practitioners who provide their care, the organizations within which care is provided, the network of youth service systems (e.g., child welfare, education), and the policy context (e.g., reimbursement regulations and incentives). We suggest six strategies for future research on EBPs within the youth mental health ecosystem, including reliance on the deployment-focused model of development and testing, testing the mettle of current EBPs in everyday practice contexts, using the heuristic potential of usual care, testing restructured and integrative adaptations of EBPs, studying the use of treatment response feedback to guide clinical care, and testing models of the relation between policy change and EBP implementation.

A Pilot Study of Computer-Assisted Cognitive Behavioral Therapy for Childhood Anxiety in Community Mental Health Centers

Anxiety disorders among children are common, disabling, and run a chronic course without treatment. Cognitive behavioral therapy (CBT) has shown robust efficacy for childhood anxiety. However, dissemination of CBT into community mental health centers (CMHCs) is limited. Computer-assisted CBT (CCBT) programs have been developed to improve dissemination by providing a structured treatment format that allows therapists to reliably deliver evidence-based treatments with fidelity. In this pilot study involving therapists with limited CBT experience, the effectiveness, feasibility, and acceptability of a CCBT program, Camp Cope-A-Lot (Khanna & Kendall, 2008b), were examined in three CMHCs. Seventeen youth ages 7–13 years and diagnosed with a primary anxiety disorder were enrolled. Assessments were conducted by a rater not involved in treatment at baseline and posttreatment. Significant reductions in anxiety severity and impairment were demonstrated at the posttreatment assessment. High levels of family satisfaction were reported. These results provide preliminary support for the effectiveness of a computer-assisted treatment into CMHCs and warrant replication in a controlled setting.

Anxious youth in research and service clinics

With the current focus on increasing utilization of empirically supported treatments, knowledge of sample differences and similarities has increasing importance. The present study compared anxiety-disordered youth (age 7-13) from (a) five Norwegian service clinics (SC, N = 111) to (b) a university research clinic (RC) in Philadelphia, USA (N = 144) on pre-treatment characteristics measured by the Multidimensional Anxiety Scale for Children, Child Behavior Checklist, Teacher Report Form, Anxiety Disorders Interview Schedule, and Children's Global Assessment Scale (CGAS). SC youth demonstrated higher levels of anxiety based on child- (d = 0.42-1.04) and parent-report (d = 0.53) and conduct problems based on parent-report (d = 0.43) compared to RC youth. SC youth was more functionally impaired on the CGAS (d = 0.97), whereas RC youth evidenced a greater number of diagnoses (d = 0.63). The two samples were equivalent regarding parent-reported symptoms of affective, somatic, attention-deficit/hyperactivity, and oppositional problems. Future directions and clinical implications are discussed.