Clinician knowledge and utilization of empirically-supported treatments for maltreated children

Attachment security as an outcome and predictor of response to trauma-focused cognitive-behavioral therapy among maltreated children with posttraumatic stress: A pilot study

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a frontline intervention for posttraumatic stress disorder (PTSD) symptoms among maltreated children. Research suggests that active caregiver participation predicts positive treatment outcomes, but these studies are often based on the perception of the caregiver. Youth perceptions of the caregiver as a source of support who might help confront distressing memories (i.e., attachment security) and how they relate to TF-CBT treatment are unexplored. This paper uses data from a small randomized controlled feasibility trial of TF-CBT to conduct a pilot examination of whether (a) attachment security may improve through the course of TF-CBT, and (b) pre-treatment attachment security predicts response to TF-CBT for the amelioration of posttraumatic stress. Results favored the conclusion that those beginning treatment with attachment insecurity may demonstrate improvement for this outcome by the end of treatment (n = 8; t = 3.3, p = .013, Cohen's d = 1.17). However, although significant improvements were found over the course of treatment for PTSD, there was no evidence that pre-treatment attachment security predicted PTSD outcome (n = 29; ∆R² < .01, ∆F(1,26) = .001, p = .969). The limitations of the current pilot study are discussed, as well as directions for future research.

Integrating Animal-Assisted Therapy Into TF-CBT for Abused Youth With PTSD: A Randomized Controlled Feasibility Trial

This clinical trial examined animal-assisted therapy (AAT) as an adjunct to Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) for abused youth with posttraumatic stress disorder (PTSD). Youth between the ages of 6 and 17 (M = 11.79, SD = 3.08) were randomized to receive standard TF-CBT or TF-CBT with adjunctive AAT (TF-CBT+AAT) employing retired service dogs. Feasibility metrics evaluating the addition of AAT were collected in addition to common clinical outcomes evaluated in TF-CBT trials. The inclusion of AAT increased the number of potential participants who declined participation and there were no noted benefits for treatment retention or satisfaction with services. Analyses showed that the inclusion of AAT did not enhance improvement of PTSD symptom severity (β = .90, t = .94, p = .351) or a number of other outcomes. On the contrary, there were indications from analyses and clinician feedback that AAT may have attenuated improvement in many cases. This study identified a number of important feasibility considerations in the design of studies testing AAT. However, the results examining clinical outcomes suggest that the inclusion of AAT with TF-CBT in the treatment of maltreated youth with PTSD is not warranted at this time.

Disseminating TF-CBT: A Mixed Methods Investigation of Clinician Perspectives and the Impact of Training Format and Formalized Problem-Solving Approaches on Implementation Outcomes

BACKGROUND

Trauma Focused-Cognitive Behavioural Therapy (TF-CBT) has been established as an evidence-based treatment for youth with traumatic stress symptoms. The versatility of TF-CBT in conjunction with its established effectiveness has led to its widespread dissemination. However, dissemination efforts have not always translated into sustainability, which has prompted a more thorough investigation into those factors that impact implementation and encouraged the development of strategies that promote sustainability. Toward this end, the aims of this study were to: (1) determine which components of TF-CBT clinicians found the most difficult to implement; (2) explore clinicians' perceptions as to why these components were challenging; and (3) examine whether the use of formalized problem-solving approaches (FPSAs) or training format was associated with implementation outcomes.

METHODS

A mixed methods design was utilized to analyse survey data from mental health professionals (N = 85) who received TF-CBT training. Thematic analysis explored responses to questions concerning those TF-CBT components respondents found most difficult to implement, while bivariate analyses helped determine whether training format or the use of FPSAs was associated with training engagement, confidence in delivering TF-CBT, fidelity or sustainability.

RESULTS

Clinicians perceived the same three components of TF-CBT as most difficult regardless of the type of training they received, and provider, youth, caregiver, and organizational-related themes emerged from thematic analysis. Bivariate analyses indicated more extended training formats and the use of FPSAs were associated with greater implementation success.

CONCLUSION

Findings suggest that perceived difficulty of TF-CBT components did not vary by training format, but more extended formats and the use of FPSAs were associated with more favourable implementation outcomes. Implementers should consider ways to utilize FPSAs within training programs, as well as focus on content identified by clinicians as difficult, as this may assist clinicians in developing skills and managing implementation barriers.

A survey of evidence-based practice, training, supervision and clinician confidence relating to post-traumatic stress disorder (PTSD) therapies in UK child and adolescent mental health professionals

Background: Post-Traumatic Stress Disorder (PTSD) in children and adolescents has received increasing recognition in recent decades. Despite development of treatments and improved dissemination efforts, research has identified a number of barriers to implementing these approaches. Objective: This study sought to understand what interventions mental health professionals working with children and adolescents utilised to treat PTSD, their training and supervision, their confidence in assessing and treating PTSD, and how these factors relate to clinicians characteristics (e.g. age, gender, professional background). Method: The study comprised an internet-delivered survey of clinicians working in child and adolescent mental health services in the UK (N = 716). Results: Many clinicians (>40%) had not received training in working with PTSD, with considerable variation between professional background. Lack of training and supervision was associated with reduced clinician confidence in treating children with PTSD (possible range 0-10; training M = 7.54, SD = 1.65, no training M = 5.49, SD = 2.29; supervision M = 7.53, SD = 1.63, no supervision M = 5.98, SD = 2.35). Evidence-based therapies for PTSD such as Trauma-Focused Cognitive-Behavioural Therapy and Eye Movement Desensitisation and Reprocessing were only endorsed modestly by clinicians (58.4% and 37.5%, respectively). Regression analyses identified that lack of training and supervision were significant barriers to the use of evidence-based interventions. Other predictors of clinician confidence and use of evidence-based interventions included profession and years of experience. Participants almost universally wanted more training in working with PTSD. Conclusions: Evidence-based treatments are not currently universally delivered by mental health professionals in the UK, with certain professions particularly lacking training and confidence with this condition. Training around trauma and PTSD may be an ongoing need to boost and maintain confidence in working with PTSD in youth.

Determinants of Implementing Evidence-Based Trauma-Focused Interventions for Children and Youth: A Systematic Review

A systematic review was conducted to identify determinants (barriers and facilitators) of implementing evidence-based psychosocial interventions for children and youth who experience emotional or behavioral difficulties due to trauma exposure. Determinants were coded, abstracted, and synthesized using the Exploration, Preparation, Implementation, and Sustainment framework. Twenty-three articles were included, all of which examined implementation of Trauma-Focused Cognitive Behavioral Therapy or Cognitive-Behavioral Intervention for Trauma in Schools. This review identified multilevel and multiphase determinants that can be addressed by implementation strategies to improve implementation and clinical outcomes, and suggests how future studies might address gaps in the evidence base.

Predictors of Attrition Among Young Children Receiving Trauma-Focused Therapy

Findings from studies of predominately school-aged children indicate that few children complete trauma-focused treatment; however, researchers have not specifically examined risk factors for dropout among young trauma-exposed children. The purpose of the present study was to investigate risk factors for attrition among young children receiving trauma-focused therapy. Study participants were 189 treatment-seeking children aged 3-5 years (M = 4.86 years, SD = 0.71; 54.1% female, 47.7% White) and their nonoffending legal guardian(s). Child and family characteristics, number of traumatic events, and pretreatment posttraumatic stress symptoms (PTSS) were examined in relation to two attrition definitions: (a) clinician-rated dropout and (b) whether the child received an adequate treatment dose (i.e., 12 or more sessions). Although 70.3% of children prematurely terminated therapy per their clinician, a nearly equivalent portion (67.4%) received an adequate treatment dose. Family characteristics were largely not associated with attrition, although residing farther from the clinic was related to clinician-rated treatment dropout, OR = 0.96. As expected, higher levels of externalizing symptoms were associated with clinician-rated dropout and inadequate dose status, ORs = .95 and .96, respectively, whereas lower levels of trauma-related anger were related to clinician-rated treatment completion, OR = 1.03, and lower levels of PTSS and sexual concerns corresponded with an increased likelihood the child received an inadequate treatment dose, ORs = 1.03 and 1.02, respectively. Thus, child and family factors appear to play a small role in predicting attrition; however, higher levels of externalizing problems and lower levels of PTSS may increase the risk for dropout.

A systematic review of the clinician related barriers and facilitators to the use of evidence-informed interventions for post traumatic stress

BACKGROUND

A number of evidence-informed interventions for PTSD have been developed and recommended by clinical guidelines. Despite efforts to disseminate these approaches, there remains a gap between evidence and practice, and research has started to identify a number of barriers to the implementation of evidence-informed interventions.

METHODS

This systematic review aimed to synthesise the relevant literature, both quantitative and qualitative, relating to clinicians' perceived barriers and facilitators. Literature searches were conducted to identify relevant studies. Data were analysed using content analysis to categorise key barriers and facilitators.

RESULTS

A literature search identified 34 relevant studies. Four levels of barriers and facilitators were identified, covering intervention, client, clinician and system factors. The most commonly cited barriers identified include inflexibility of manualised approaches, fear of increasing client distress, working with comorbidities and a lack of training and support. Quality appraisal rated the majority of studies as strong, with five studies receiving an adequate rating.

LIMITATIONS

The review was limited to studies published in the English language, therefore introducing a risk of bias as perceived barriers and facilitators may be culturally influenced. Additionally the heterogeneity of studies may impact upon comparability, only allowing for a broad analysis and not exploring barriers and facilitators in more detail.

CONCLUSIONS

Lack of training, confidence and knowledge relating to the implementation of evidence-informed interventions for PTSD were commonly reported. A better-informed understanding into the challenges and facilitators experienced by clinicians can help inform implementation needs and should be considered in the development and implementation of training initiatives.

Users' experiences of trauma-focused cognitive behavioural therapy for children and adolescents: a systematic review and metasynthesis of qualitative research

Trauma-focused cognitive behavioural therapy (TF-CBT) is an effective intervention for post-traumatic stress disorder, yet implementation may be hindered by practitioners' concerns about how treatment is experienced by users. This metasynthesis systematically reviews qualitative evidence on youth and caregivers' experiences of TF-CBT to better understand user perspectives on process and outcomes of treatment. A systematic review and metasynthesis were undertaken for qualitative studies of treatment experience related to TF-CBT. Data were extracted according to Evidence for Policy and Practice Information and Coordinating Centre guidelines, and studies were critically appraised using Critical Appraisal Skills Programme checklists. Findings from included studies were coded and synthesized using thematic synthesis methodology. Eight studies were selected after a full-text review of 39 papers. Findings were organised around nine sub-themes, under three broad thematic categories: 'engagement in TF-CBT'; 'experience of treatment components'; and 'therapeutic outcomes'. Youth were often unclear about what to expect from treatment and concerned about (in)compatibility with their therapist. Youth reports indicated how such misgivings can be addressed through early psychoeducation and efforts to strengthen the therapeutic alliance. Once underway, treatment was viewed as a place of refuge and validation, aided by therapist competence and confidentiality. Youth and caregivers felt that constructing a trauma narrative was instrumental for recovery. Cognitive-behavioural coping techniques were useful during treatment and in the long-term. While participants in TF-CBT may begin treatment with unclear expectancies, careful attention to early engagement and other process issues can optimise process and outcomes. Implications for clinical practice and further research are discussed.

Measuring Youth Residential Care Provider Attitudes

Abstract. In this study the 15-item Evidence-Based Practices Attitude Scale (EBPAS), a measure designed to assess attitudes toward the adoption of EBPs, was collected from administrators of residential care facilities for youth in the United States. As the EBPAS was administered to a different sample for which it was originally developed (i.e., community mental health), we conducted a Confirmatory Factor Analysis (CFA) to investigate if its factor structure was maintained. Results confirm the factor structure of the EBPAS as a valid measure of attitude toward evidence-based practice among youth residential care providers. Limitations and areas of future research are discussed.

Emotionale Reaktionen, Einstellungen und Behandlungstechniken bei Kindern mit einer Posttraumatischen Belastungsstörung

Zusammenfassung. Theoretischer Hintergrund: In der Forschung zu Stigmatisierungen von psychisch erkrankten Personen wurde festgestellt, dass auch professionelle Helferinnen und Helfer Vorurteile angeben. Zudem existieren zahlreiche Untersuchungen, die zeigen, dass viele Psychotherapeutinnen und Psychotherapeuten die Anwendung konfrontativer Interventionen vermeiden. Fragestellung: Kinder- und Jugendlichenpsychotherapeutinnen und – psychotherapeuten (KJPT) wurde eine von vier verschiedenen Fallvignetten vorgelegt und es sollte untersucht werden, inwieweit die Behandlungsbereitschaft und die emotionalen Reaktionen auf den beschriebenen Patienten in Abhängigkeit von der Verantwortungszuschreibung für die Beschwerden variieren. Die Therapeutinnen und Therapeuten wurden ebenfalls gebeten, Interventionen anzugeben, die sie während einer Behandlung durchführen würden. Methodik: Zusammen mit der Psychotherapeutenkammer Niedersachsen wurden von Mai 2016 – Juni 2016 eine von vier verschiedenen Fallvignetten sowie ein Fragebogen an 841 KJPT versendet. Ergebnisse: 77 KJPT (9.16 %) beantworteten den Fragebogen. Trotz unterschiedlicher Verantwortungszuschreibung variierte die Behandlungsbereitschaft zwischen den vier Gruppen nicht. Von den vorgeschlagenen Interventionen würde die Konfrontation mit „hot spots“ am seltensten angewendet werden. Schlussfolgerungen: Therapeutinnen und Therapeuten sind generell bereit, Patientinnen und Patienten mit einer Posttraumatischen Belastungsstörung zu behandeln, auch wenn sie die Patientinnen und Patienten als verantwortlich für ihre Beschwerden ansehen. Die Ergebnisse legen nahe, dass eine leitlinienkonforme Behandlung selten durchgeführt werden würde.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Perceived parental rejection mediates the effects of previous maltreatment on emotional and behavioural outcomes in Chinese adolescents whereas mental illness has no moderating effect

Objective

This study assessed the mediating role of perceived parental rejection in the relationship between childhood maltreatment experience and behavioural problems in Chinese adolescents.

Methods

A total of 2484 adolescents (1305 males and 1179 females; aged 12–16 years) from Hunan Province, China, participated in the study. Behavioural problems, parental rejection scores and child abuse experiences were evaluated by the Child Behavior Checklist (parental version), the Memories of Parental Rearing Behavior Scale and the Childhood Trauma Questionnaire, separately. Mediating effects were examined by structural equation modelling using Amos 20 software.

Results

The study found that perceived maternal rejection partially mediated the association between abuse and internalising behaviours in the male cohort, whereas perceived father’s rejection partially mediated this association in the female cohort. However, mental illness had no moderating effect on these relationships.

Conclusion

These results are consistent with the literature on maltreatment and parent-child relationships and provide empirical support for the view that emotional and behavioural problems related to perceived parental rejection underlie the development of psychosocial problems in adolescents.

Structured Trauma-Focused CBT and Unstructured Play/Experiential Techniques in the Treatment of Sexually Abused Children: A Field Study With Practicing Clinicians

Structured, trauma-focused cognitive-behavioral therapy (CBT) techniques are widely considered an effective intervention for children who experienced sexual abuse. However, unstructured (i.e., nondirective) play/experiential techniques have a longer history of widespread promotion and are preferred by many practicing clinicians. No evidence is available, however, to determine how the integration of these techniques impacts treatment outcome. In this study, community-based clinicians who received training in a structured, trauma-focused cognitive-behavioral intervention administered pretreatment and posttreatment evaluations to 260 sexually abused children presenting with elevated posttraumatic stress. In addition, they completed a questionnaire describing the treatment techniques implemented with each child. Overall, significant improvement was observed for each of the six clinical outcomes. Regression analyses indicated that technique selection was a significant factor in posttreatment outcome for posttraumatic stress, dissociation, anxiety, and anger/aggression. In general, a greater utilization of the structured CBT techniques was related to lower posttreatment scores, whereas a higher frequency of play/experiential techniques was associated with higher posttreatment scores. However, no interaction effects were observed. The implication of these findings for clinical practice and future research are examined.

Use of evidence-based interventions in child welfare: Do attitudes matter?

Implementation of evidence-based programs in progressed slowly, with the majority of services in child welfare settings lacking empirical evidence for effectiveness. In other settings, research has identified providers' attitudes about evidence-based practices (EBPs) as a potential barrier to adoption of EBPs. As little research has focused on the role of attitudes in influencing use after training in an EBP in child welfare, the potential for attitudes to impede implementation efforts in child welfare is unclear. This study addressed this question in a sample of 55 caseworkers and therapists randomly assigned to enhanced support to use an EBP following training or a training-only condition. Information on providers' use of the intervention after training and their attitudes about EBPs were measured for up to five time points. Results indicate that attitudes did not predict providers' use of the EBP, and attitudes did not change overall or in the enhanced condition that provided greater exposure to the intervention. Providers perceived of requirements to use a practice as more influential in their use than their openness to EBPs. However, those who were more open to EBPs were more likely to participate in implementation support after the training, suggesting that openness facilitates participation in activities that support use of a new intervention.

Early Treatment Response in Children and Adolescents Receiving CBT for Trauma

OBJECTIVES

To investigate the incidence and correlates of early treatment response among youth receiving cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD).

METHODS

56 youth who participated in a randomized controlled trial of CBT for PTSD and D-cycloserine were included. Youth with PTSD symptoms below clinical cutoff after Session 4 of a 12-session protocol were classified as early treatment responders (32% of parent reports, 44.6% of child reports). Pretreatment characteristics were examined in relation to responder status.

RESULTS

Lower levels of pretreatment PTSD, depression, and anxiety symptoms and fewer trauma types were related to child- and parent-reported responder status (d = .57, d = .52, respectively). Early treatment response was maintained at follow-up.

CONCLUSIONS

Pretreatment symptoms levels and number of traumas may play an important role in predicting early treatment response. Correlates of early treatment response may provide avenues for identifying youth who could benefit from abbreviated protocols.

Perceptions and Use of EMDR Therapy in Rape Crisis Centers

Sexual violence is pervasive and generates significant trauma symptoms that can last a lifetime for survivors. Rape crisis centers provide critically important services for survivors of child sexual abuse and adult sexual assault, including individual and group counseling. Eye movement desensitization and reprocessing (EMDR) has been found to be an effective treatment for a wide array of trauma symptoms in both children and adults. This study sought to determine the extent to which rape crisis centers use EMDR therapy, practitioners’ perceptions of EMDR, and the provider characteristics that might support or hinder implementation of EMDR in this setting. A statewide web-based survey generated responses from 76 counselors working within 47 rape crisis centers. Results indicate that there is a low-use rate of EMDR (8%) in this setting, perceptions of EMDR were predominately marked by uncertainty, reflecting a lack of familiarity, but there is strong interest in receiving training. The desire for training is complicated by the range of education levels of counseling staff in rape crisis centers with only 54% holding advanced degrees. There is an opportunity and need to build capacity for the implementation of EMDR in this vital service sector, but there are also significant challenges that will need to be addressed.

Caregiver Perceptions of Clinical Decision-Making for the Treatment of Children

Many sources of information impact one's clinical decision-making (CDM) (e.g. clinical intuition, previous experience, research results). Relatively little is known about the clients' perspectives of these factors. The current study is an examination of perceptions of the favorability of various CDM influences held by caregivers of children presenting for mental health treatment (n = 371). Responses to a questionnaire showed that caregivers overwhelmingly favored a treatment decision based on current scientific research, with one's clinical experience being the second most favored influence. Other influences, such as colleague consultation and clinical intuition, were less favorable.

Practitioners' views and use of evidence-based treatment: positive attitudes but missed opportunities in children's services

The extent evidence-based treatments (EBTs) are used in clinical practice within the Australian therapeutic child welfare sector is unknown. In this study, we investigated practitioners' knowledge, attitudes, and use of EBT when providing interventions to children and families and how the intended outcomes of interventions are evaluated. Practitioners (N = 112) from 41 non-government organizations were surveyed and reported few barriers to implementing EBTs and positive attitudes. While just over half the practitioners surveyed provided an accurate definition of EBT, 72 % of practitioners reported using EBTs in their clinical practice. Of those, 88 % reported modifying the EBT, however interventions were rarely evaluated systematically. Implications for the use of EBTs, how they are modified, and the role of systematic evaluation are discussed.

Web-Based Training for an Evidence-Supported Treatment: Training Completion and Knowledge Acquisition in a Global Sample of Learners

The purpose of this investigation is to describe the characteristics of professional and preprofessional learners who registered for and completed TF-CBTWeb, a modular, web-based training program designed to promote the dissemination of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and to demonstrate the feasibility of this method of dissemination. Between October 1, 2005, and October 1, 2012, a total of 123,848 learners registered for TF-CBTWeb, of whom 98,646 (79.7%) initiated the learning activities by beginning the first module pretest. Of those, 67,201 (68.1%) completed the full training. Registrants hailed from 130 countries worldwide, and they had varied educational backgrounds, professional identities (both professional and preprofessional), and a range of experience working with child trauma victims. Learners who were from the United States, students, those with master's degrees, and those with fewer years of experience working with child trauma victims tended to have the highest course completion rates. Learners displayed significant increases in knowledge about each component of TF-CBT, based on module pretest and posttest scores. The advantages and limitations of this web-based training program evaluation are discussed, while important implications for the use of web-based trainings are reviewed.

A national survey of child advocacy center directors regarding knowledge of assessment, treatment referral, and training needs in physical and sexual abuse

Mental health services are a core component of child advocacy centers in the United States. Child advocacy center directors were surveyed about (a) trauma and posttraumatic stress disorder; (b) referral criteria for treatment of abuse victims; (c) evidence-based treatments for abused children; (d) reliable, valid, and normed measures helpful in assessment; and (e) training needs. Directors accurately identified posttraumatic stress disorder symptoms, but additional symptoms were misidentified. Directors identified best practices for assessment and treatment, but they misidentified non-evidence-based practices. Primary reasons for referral for services included severity of abuse and emotional response of the child. However, referrals based on assessment findings were not a high priority. Directors expressed some training needs for staff consistent with issues identified in the study.

Burden of proof: the evidence clinicians require before implementing an intervention

BACKGROUND

Greater implementation of evidence-based practice for children and adolescents is a current emphasis in the mental health field; however, there is a need to understand how best to disseminate these interventions and convince community clinicians to use them.

METHOD

A sample of 255 clinicians reported on the likelihood that they would use an intervention given various types of evidence.

RESULTS

Case studies and clinical trials with an active or placebo control group scored as the most preferred types of evidence; however, more positive attitudes toward evidence-based practice predicted preferences for clinical trials, but were not related to case studies.

CONCLUSION

Implementation of evidence-based practice may be improved by greater dissemination of case studies demonstrating the use of these interventions in 'real world' settings. In addition, fostering a greater appreciation of research-derived interventions among clinicians appears necessary.

Step one within stepped care trauma-focused cognitive behavioral therapy for young children: a pilot study

This pilot study explored the preliminary efficacy, parent acceptability and economic cost of delivering Step One within Stepped Care Trauma-Focused Cognitive Behavioral Therapy (SC-TF-CBT). Nine young children ages 3-6 years and their parents participated in SC-TF-CBT. Eighty-three percent (5/6) of the children who completed Step One treatment and 55.6 % (5/9) of the intent-to-treat sample responded to Step One. One case relapsed at post-assessment. Treatment gains were maintained at 3-month follow-up. Generally, parents found Step One to be acceptable and were satisfied with treatment. At 3-month follow-up, the cost per unit improvement for posttraumatic stress symptoms and severity ranged from $27.65 to $131.33 for the responders and from $36.12 to $208.11 for the intent-to-treat sample. Further research on stepped care for young children is warranted to examine if this approach is more efficient, accessible and cost-effective than traditional therapy.

Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children

Young children who are exposed to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel interventions that are more accessible, efficient, and cost-effective are needed to improve access to evidence-based treatment. Stepped care models currently being developed for mental health conditions are based on a service delivery model designed to address barriers to treatment. This treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established evidence-based practice, was developed into a stepped care model for young children exposed to trauma. Considerations for developing the stepped care model for young children exposed to trauma, such as the type and number of steps, training of providers, entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting monitoring system, are discussed. This model of stepped care for young children exposed to trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped care approaches to treating other types of childhood psychiatric disorders. Future research needed on Stepped Care TF-CBT is discussed.

Treatment beliefs and techniques of clinicians serving child maltreatment survivors

A significant focus in the child maltreatment field is greater dissemination and implementation of evidence-based treatments (EBTs). Research has attempted to identify attitudes toward EBTs and training experiences that predict clinicians' use of EBTs; however, these findings have yielded mixed results. This study reports on the results of a nationwide (United States) sample of 256 clinicians serving child maltreatment survivors, who completed questionnaires assessing beliefs about the clinical process, treatment technique selection, and attitudes toward EBTs. Psychometric data are presented on two new scales. The first scale examines clinicians' beliefs about two components of the clinical process: (1) the extent to which treatment should be structured/directed by the clinician and (2) children's verbal capacity to discuss traumatic events. The second scale assesses clinician-reported selection of various treatment techniques and contains four subscales: Cognitive-Behavioral, Play/Experiential, Psychodynamic, and Uncommon. Using these scales, a series of analyses were performed to determine which attitudes, beliefs, and training variables were associated with the selection of treatment techniques. After controlling for the impact of other variables, significant associations between the two clinical process beliefs and cognitive-behavioral and play/experiential techniques utilization were observed. Implications of these results for increasing implementation of EBTs with child maltreatment survivors are discussed.

Advances toward evidence-based practice: where to from here?

Evidence-based practice has a long history; however, attempts to bridge the gap between science and practice have been only partially effective and much work remains to be done. Part of the problem has been the unilateral approach associated with dissemination of research findings to clinical practitioners. In this special series, Goldfried and colleagues (2014--this issue) suggest a two-way bridge, in which practitioners are afforded the opportunity to disseminate their rich clinical experiences to researchers as well. In this manner, a more collaborative working relationship is espoused. Surveys of practitioners on the use of CBT procedures in the treatment of panic disorder, social anxiety disorder, and generalized anxiety disorder are described. The findings are reviewed and limitations associated with the surveys are noted. Finally, future directions are suggested for rapprochement, hopefully resulting in a greater synthesis of research and practice.

Childhood sexual abuse: community-based treatment practices and predictors of use of evidence-based practices

BACKGROUND

Cognitive behavior therapy with abuse-focused components is empirically supported for children/adolescents who have experienced childhood sexual abuse (CSA). We examined the extent to which community-based psychologists use evidence-based practices (EBP) for CSA and identified predictors of EBP use.

METHOD

Psychologists (N = 231) providing CSA treatment services to children/adolescents in Ontario (Canada) were identified through the first census of child and adolescent psychology clinicians registered with the College of Psychologists of Ontario. Participants completed a questionnaire on treatment strategies, sociodemographics, work setting, treatment provision, and attitudes toward EBP. Data were collected between December 2009 and June 2010.

RESULTS

The majority (78%) of psychologists providing CSA services reported never having received training in specific treatment approaches for this population. Only 5% of psychologists received training in the EBP of trauma-focused cognitive behavior therapy. Multiple regressions indicated that age, theoretical orientation, continuing education, and attitudes predicted the use of an empirically based intervention for CSA.

CONCLUSION

Study findings show that few community-based psychologists have received training in specific treatment approaches for CSA victims and very few are trained to deliver EBP for this population. There are ethical concerns about the practice of psychologists who are untrained and unsupervised doing this work. Research findings, which underline the need for training, supervision, and continuing education, need to be translated into clinical practice.

Step one within stepped care trauma-focused cognitive behavioral therapy for young children: a pilot study

This pilot study explored the preliminary efficacy, parent acceptability and economic cost of delivering Step One within Stepped Care Trauma-Focused Cognitive Behavioral Therapy (SC-TF-CBT). Nine young children ages 3-6 years and their parents participated in SC-TF-CBT. Eighty-three percent (5/6) of the children who completed Step One treatment and 55.6 % (5/9) of the intent-to-treat sample responded to Step One. One case relapsed at post-assessment. Treatment gains were maintained at 3-month follow-up. Generally, parents found Step One to be acceptable and were satisfied with treatment. At 3-month follow-up, the cost per unit improvement for posttraumatic stress symptoms and severity ranged from $27.65 to $131.33 for the responders and from $36.12 to $208.11 for the intent-to-treat sample. Further research on stepped care for young children is warranted to examine if this approach is more efficient, accessible and cost-effective than traditional therapy.

Evidence-based treatments for traumatized children and adolescents

This article reviews recent advances in empirically supported psychotherapeutic treatments for children and adolescents experiencing trauma and provides a brief summary of available interventions, as well as a context for their use. We highlight the American Academy of Child and Adolescent Psychiatry's recent practice guidelines for trauma treatment and discuss their implications for clinicians, including the benefits of involving caregivers in treatment and the rationale for using practices that are specifically trauma-focused as first-line intervention. Finally, we discuss the status of research on the real-world implementation of these therapies and the need for further research, particularly regarding clinician knowledge and use of empirically supported practices, potential stepped-care approaches to trauma treatment, and the need to reduce attrition in child trauma research and practice.

Parent-child interaction therapy: an evidence-based treatment for child maltreatment

It is common practice to augment efficacious treatment protocols for special populations (Durlak & DuPre, 2008), but this is often done before establishing that standard services are not appropriate. In this randomized controlled trial with families at risk or with a history of maltreatment (N = 151), we investigated the effectiveness of standard 12-session Parent-Child Interaction Therapy (PCIT). This is in contrast to other PCIT studies with similar parents, which have allowed for longer and sometimes variable treatment length and with modifications to PCIT protocol. After treatment and compared to Waitlist, mothers reported fewer child externalizing and internalizing behaviors, decreased stress, and were observed to have more positive verbalizations and maternal sensitivity. These outcomes were equivalent or better than outcomes of our previous PCIT trial with high-risk families (Thomas & Zimmer-Gembeck, 2011) when treatment length was variable and often longer. These findings support standard protocol PCIT as an efficacious intervention for families in the child welfare system.