Measurement training and feedback system for implementation of evidence-based treatment for adolescent externalizing problems: protocol for a randomized trial of pragmatic clinician training

Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study

BACKGROUND

Internalizing disorders (IDs), primarily depression and anxiety, are highly prevalent among adolescents receiving community-based treatment for substance use disorders (SUDs). For such clients, interventions that do not holistically address both SUDs and IDs are less effective.

OBJECTIVE

This pilot treatment development study aims to develop and test a modular treatment protocol for addressing cooccurring IDs among adolescents (aged 13 to 18 years) enrolled in routine care for substance use problems: Family Support Protocol for Adolescent Internalizing Disorders (Fam-AID). As an adjunctive protocol, Fam-AID will not require clinicians to markedly alter existing base practices for SUD. It will be anchored by 3 evidence-based foundations for treating cooccurring adolescent IDs: family engagement techniques, transdiagnostic individual cognitive behavioral therapy techniques, and family psychoeducation and safety planning.

METHODS

This quasi-experimental study will proceed in 2 stages. The pilot stage will use rapid-cycle prototyping methods in collaboration with end-user stakeholders to draft protocol delivery and fidelity guidelines adapted from existing resources, solicit provider and client input on protocol content and delivery via cognitive interviewing, and pilot prototype components on 4 to 6 cases. The second stage will be an interrupted time series study for 60 comorbid SUD+ID cases across 2 sites serving diverse adolescents: 30 will receive treatment as usual (TAU); following clinician training in the protocol, 30 new cases will receive TAU enhanced by Fam-AID. For aim 1, the focus is on evaluating the acceptability of the Fam-AID protocol through therapist and client interviews as well as assessing fidelity benchmarks using therapist- and observer-reported protocol fidelity data. For aim 2, the plan is to compare the effects of TAU only cases versus TAU+Fam-AID cases on family treatment attendance and on adolescent ID and substance use symptoms, with measurements taken at baseline and at 3-month and 6-month follow-ups.

RESULTS

Study recruitment will begin in April 2025.

CONCLUSIONS

We anticipate that Fam-AID will contain 5 treatment modules that can be delivered in any sequence to meet client needs: family engagement of primary supports in treatment planning and services; relational reframing of family constraints, resiliencies, and social capital connected to the adolescent's ID symptoms; functional analysis of the adolescent's ID symptoms and related behaviors; cognitive behavioral therapy to address the adolescent's ID symptoms and functional needs, featuring 3 core techniques (emotion acceptance, emotional exposure, and behavioral activation) to address negative affect and emotional dysregulation; and family psychoeducation and safety planning focused on education about comorbid SUD+ID and prevention of adolescent self-harm. If the abovementioned modules are found to be feasible and effective, Fam-AID will offer a set of pragmatic interventions to SUD clinicians for treating cooccurring IDs in adolescent clients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06413979; https://www.clinicaltrials.gov/study/NCT06413979.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/64332.

Pilot Trial of Online Measurement Training and Feedback in Family Therapy for Adolescent Behavior Problems

OBJECTIVE

Pragmatic procedures for sustaining high-fidelity delivery of evidence-based interventions are needed to support implementation in usual care. This study tested an online therapist training system, featuring observational coder training and self-report fidelity feedback, to promote self-report acumen and routine use of family therapy (FT) techniques for adolescent behavior problems.

METHOD

Therapists (N = 84) from nine substance use and mental health treatment sites reported on 185 adolescent clients. Therapists submitted baseline data on FT technique use with clients, completed a workshop introducing the 32-week training system, and were randomly assigned by site to Core Training versus Core Training + Consultation. Core Training included a therapist coder training course (didactic instruction and mock session coding exercises in 13 FT techniques) and fidelity feedback procedures depicting therapist-report data on FT use. Consultation convened therapists and supervisors for one-hour monthly sessions with an external FT expert. During the 32 weeks of training, therapists submitted self-report data on FT use along with companion session audiotapes subsequently coded by observational raters.

RESULTS

Therapist self-report reliability and accuracy both increased substantially during training. Observers reported no increase over time in FT use; therapists self-reported a decrease in FT use, likely an artifact of their improved self-report accuracy. Consultation did not enhance therapist self-report acumen or increase FT use.

CONCLUSIONS

Online training methods that improve therapist-report reliability and accuracy for FT use may confer important advantages for treatment planning and fidelity monitoring. More intensive and/or different training interventions appear needed to increase routine FT delivery.

Testing a community developed training protocol for an evidence-based treatment

The implementation of evidence-based treatments (EBTs) in community behavioral health settings is a recommended practice, yet training experienced by community-based clinicians may require novel and creative training methods. The current study focused on creating a training protocol for Alternative for Families: a Cognitive-Behavioral Therapy from both evidence-based foundations and community-based agency feedback to promote better EBT integration into agencies. Twenty-four clinicians from three agencies were trained using a community-informed training protocol. Outcomes for clinician-reports of organizational functioning, self-reports of skill and knowledge, and observational single-subject data of clinician skills were assessed. Minimal improvements were found for clinician skills across self-report and observations. More research on tailoring trainings to meet needs of community agencies and clinicians should be explored to determine best practice in wide-scale implementation efforts.

Online Training of Community Therapists in Observational Coding of Family Therapy Techniques: Reliability and Accuracy

A foundational strategy to promote implementation of evidence-based interventions (EBIs) is providing EBI training to therapists. This study tested an online training system in which therapists practiced observational coding of mock video vignettes demonstrating family therapy techniques for adolescent behavior problems. The study compared therapists ratings to gold-standard scores to measure therapist reliability (consistency across vignettes) and accuracy (approximation to gold scores); tested whether reliability and accuracy improved during training; and tested therapist-level predictors of overall accuracy and change in accuracy over time. Participants were 48 therapists working in nine community behavioral health clinics. The 32-exercise training course provided online instruction (about 15 min/week) in 13 core family therapy techniques representing three modules: Family Engagement, Relational Orientation, Interactional Change. Therapist reliability in rating technique presence (i.e., technique recognition) remained moderate across training; reliability in rating extensiveness of technique delivery (i.e., technique judgment) improved sharply over time, from poor to good. Whereas therapists on average overestimated extensiveness for almost every technique, their tendency to give low-accuracy scores decreased. Therapist accuracy improved significantly over time only for Interactional Change techniques. Baseline digital literacy and submission of self-report checklists on use of the techniques in their own sessions predicted coding accuracy. Training therapists to be more reliable and accurate coders of EBI techniques can potentially yield benefits in increased EBI self-report acumen and EBI use in daily practice. However, training effects may need to improve from those reported here to avail meaningful impact on EBI implementation.Trial Registration: The parent clinical trial is registered at www.ClinicalTrials.gov , ID: NCT03342872 (registration date: 11.10.17).

Community Implementation of MI-Enhanced Behavior Therapy for Adolescent ADHD: Linking Fidelity to Effectiveness

Evidence-based behavior therapy for adolescent ADHD faces implementation challenges in real-world settings. The purpose of this trial was to investigate the relationship between implementation fidelity and outcomes among adolescents receiving services in the active treatment arm (N = 114; Motivational Interviewing [MI]-enhanced parent-teen behavior therapy) of a community-based randomized trial of adolescent ADHD treatment. Participants received therapy from community clinicians (N = 44) at four agencies in a large, ethnically diverse metropolitan setting. Therapists provided self-report of session-by-session adherence to content fidelity checklists and audio recordings of sample sessions that were coded for MI integrity. Parents provided report of ADHD symptoms and family impairment at baseline, posttreatment, and follow-up, while academic records were obtained directly from the local school district. Results indicated that content fidelity significantly waned across the 10 manualized sessions (d = -1.23); these trends were steepest when therapy was delivered outside the office-setting and parent attendance was low. Community therapist self-report of content fidelity predicted significantly greater improvements in academic impairment from baseline to follow-up. MI delivery quality was not associated with improved outcomes; contrary to hypotheses, lower MI relational scores predicted significantly greater improvements in family impairment over time. Findings indicate that community-based outcomes for evidence-based ADHD treatment are enhanced when treatment is implemented with fidelity. Future work should revise community-based implementation strategies for adolescent ADHD treatment to prevent declines in fidelity over time, thereby improving outcomes.

Core Elements of CBT for Adolescent Conduct and Substance Use Problems: Comorbidity, Clinical Techniques, and Case Examples

Adolescent externalizing problems (AEPs), including serious conduct problems, delinquency, and substance misuse, are the most common adolescent behavioral issues in specialty care. High rates of comorbidity between conduct and substance use problems necessitate multidomain treatment strategies that can effectively address the AEP spectrum. One strategy to increase delivery of evidence-based interventions for multiproblem youth in usual care is to focus on core elements of empirically supported treatments that can be judiciously applied to clients presenting with diverse clinical profiles. This article describes six core practice elements of the cognitive-behavioral treatment (CBT) approach for AEPs: (1) Functional Analysis of Behavior Problems; (2) Prosocial Activity Sampling; (3) Cognitive Monitoring and Restructuring; (4) Emotion Regulation Training; (5) Problem-solving Training; (6) Communication Training. Integrated delivery of these core CBT elements is illustrated in two case examples, and implications for treatment planning for youth with AEPs are discussed.