Juvenile probation officers delivering an intervention for substance use significantly reduces adolescents' risky sexual behaviours

BACKGROUND

Risky sexual behaviour (RSB) is a serious public health problem for adolescents. We examined whether a contingency management intervention implemented by juvenile probation officers (JPOs) targeting substance use also impacted RSB.

METHODS

A total of 218 adolescents on probation were randomly assigned to contingency management or to probation as usual.

RESULTS

The substance use intervention delivered by JPOs reduced rates of RSB over time (β =-0.32, P =0.041 at 6months; β =-0.32, P =0.036 at 9months).

CONCLUSIONS

Adolescents receiving a substance use intervention from JPOs demonstrated reduced/prevented RSB. Interventions targeting single risk behaviours in juvenile probation populations should measure changes in other risk behaviours . Under-resourced communities lacking clinicians might consider JPOs delivering interventions.

Examining the measurement precision of behavior problems among a sample of primarily rural youth on juvenile probation and their parents

Accurate and timely intervention in the justice system is particularly critical in rural communities, given documented barriers to accessible, evidence-based services for youth. As youth in the juvenile justice system have a high prevalence of behavioral health needs, accurate assessment of those needs is a critical first step in linking youth to appropriate care. The goal of the current study is to examine the reliability of a brief assessment (the Brief Problem Checklist [BPC]) among a sample of 222 justice-involved youth and their caregivers who primarily reside in rural communities in the United States. Using a series of reliability analyses and tests of agreement, we examined whether youth and caregiver BPC produces reliable scales, the strength of the convergence among each of the BPC scales, and youth and caregiver agreement on the BPC scales. Findings support the reliability of the BPC, but not inter-rater reliability. Poor agreement between youth and caregiver reports exists for both youth internalizing and externalizing problems. Additionally, the BPC was significantly related to several theoretically relevant constructs, including treatment, substance use disorder severity, and family history of substance use. These findings lend merit to discussions about the need for more research on the reliability and validity of assessment instruments before their widespread use in guiding youth- and agency case planning decisions, along with informing conclusions about program effectiveness.

The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs

BACKGROUND

Most implementations fail before the corresponding services are ever delivered. Measuring implementation process fidelity may reveal when and why these attempts fail. This knowledge is necessary to support the achievement of positive implementation milestones, such as delivering services to clients (program start-up) and competency in treatment delivery. The present study evaluates the extent to which implementation process fidelity at different implementation stages predicts achievement of those milestones.

METHODS

Implementation process fidelity data-as measured by the Stages of Implementation Completion (SIC)-from 1287 implementing sites across 27 evidence-informed programs were examined in mixed effects regression models with sites nested within programs. Implementation process fidelity, as measured by the proportion of implementation activities completed during the three stages of the SIC Pre-Implementation phase and overall Pre-Implementation (Phase 1) and Implementation (Phase 2) proportion scores, was assessed as a predictor of sites achieving program start-up (i.e., delivering services) and competency in program delivery.

RESULTS

The predicted probability of start-up across all sites was low at 35% (95% CI [33%, 38%]). When considering the evidence-informed program being implemented, that probability was nearly twice as high (64%; 95% CI [42%, 82%]), and 57% of the total variance in program start-up was attributable to the program. Implementation process fidelity was positively and significantly associated with achievement of program start-up and competency. The magnitude of this relationship varied significantly across programs for Pre-Implementation Stage 1 (i.e., Engagement) only. Compared to other stages, completing more Pre-Implementation Stage 3 (Readiness Planning) activities resulted in the most rapid gains in probability of achieving program start-up. The predicted probability of achieving competency was very low unless sites had high scores in both Pre-Implementation and Implementation phases.

CONCLUSIONS

Strong implementation process fidelity-as measured by SIC Pre-Implementation and Implementation phase proportion scores-was associated with sites' achievement of program start-up and competency in program delivery, with early implementation process fidelity being especially potent. These findings highlight the importance of a rigorous Pre-Implementation process.

Efficient and effective measurement of provider competence in community-based substance use treatment settings: Performance of the Motivational Interviewing Coach Rating Scale (MI-CRS)

OBJECTIVE

Efficient and effective fidelity measurement is necessary to improve rigor and reduce burden of motivational interviewing (MI) implementation studies for both fidelity outcomes and quality improvement strategies. This article reports on such a measure developed with rigorous methodology and tested in community-based substance abuse treatment settings.

METHODS

This scale development study analyzed data from a National Institute on Drug Abuse study testing the Leadership and Organizational Change for Implementation (LOCI) strategy. Utilizing item response theory (IRT) methods and Rasch modeling, we analyzed coded recordings (N = 1089) of intervention sessions of 238 providers from 60 substance use treatment clinics across nine agencies in an implementation trial focusing on MI.

RESULTS

These methods yielded a reliable and valid 12-item scale representing single construct dimensionality, strong item-session maps, good rating scale functionality, and item fit. Separation reliability and absolute agreement for adjacent categories was high. No items were significantly misfitting, though one was borderline. The LOCI community providers were less likely to be scored in the advanced competence range and items were more difficult compared to the original development sample.

CONCLUSIONS

The 12-item Motivational Interviewing Coach Rating Scale (MI-CRS) showed excellent performance in a large sample of community-based substance use treatment providers using real recordings. The MI-CRS is the first efficient and effective fidelity measure appropriate for diverse ethnic groups, with interventions that are MI only or interventions that integrate MI with other treatments, and with adolescents and adults. Follow-up coaching by trained supervisors may be needed for community-based providers to achieve the highest level of MI competence.

Future-oriented repetitive thought, depressive symptoms, and suicide ideation severity: Role of future-event fluency and depressive predictive certainty

BACKGROUND

Knowing how future-oriented repetitive thought - i.e., repeated consideration of whether positive or negative outcomes will happen in one's future - leads to hopelessness-related cognitions may elucidate the role of anticipating the future in depressive symptoms and suicide ideation. This study examined future-event fluency and depressive predictive certainty - i.e., the tendency to make pessimistic future-event predictions with certainty - as mechanisms explaining the relation between future-oriented repetitive thought, depressive symptoms, and suicide ideation.

METHODS

Young adults (N = 354), oversampled for suicide ideation or attempt history, completed baseline measures of pessimistic future-oriented repetitive thought (i.e., the degree to which people consider whether negative outcomes will happen or positive outcomes will not happen in their futures), future-event fluency, depressive predictive certainty, depressive symptoms, and suicide ideation severity and were followed up 6 months later (N = 324).

RESULTS

Pessimistic future-oriented repetitive thought predicted depressive predictive certainty at 6-months, partially mediated by lower positive but not increased negative future-event fluency. There was an indirect relationship between pessimistic future-oriented repetitive thought and 6-month suicide ideation severity via 6-month depressive predictive certainty through 6-month depressive symptoms, and also via 6-month depressive symptoms (but not depressive predictive certainty) alone.

LIMITATIONS

Lack of an experimental design limits inferences about causality, and a predominantly female sample may limit generalizability by sex.

CONCLUSION

Clinical interventions should address pessimistic future-oriented repetitive thought - and its impact on how easily people can think about positive future outcomes - as one potential way to reduce depressive symptoms and, indirectly, suicide ideation.

Relations between provider adherence to a tailored motivational intervention protocol and competence in motivational interviewing

OBJECTIVES

To evaluate the association between provider adherence to Tailored Motivational Interviewing implementation strategy and motivational interviewing (MI) competence.

METHODS

156 youth-focused HIV providers enrolled in a parent implementation science trial completed: a) quarterly standardized patient assessments (SPI) during Baseline; b) a workshop, individual coaching sessions, and quarterly SPI plus feedback during Implementation; and c) quarterly SPI during Sustainment. Competence was measured using the MI-CRS and tracking data was used to assess adherence. We examined overall adherence as well as adherence to each implementation strategy in relation to MI competence.

RESULTS

Overall adherence was not associated with overall MI competence. MI competence significantly increased from Baseline to Implementation and Baseline to Sustainment. Some individual implementation strategies were associated with change in competence and the probability of achieving Intermediate/Advanced competence.

CONCLUSIONS

The results suggest that 100% percent adherence to all TMI implementation strategies may not be necessary. Completing some of the TMI implementation strategies yielded improvements in MI competence. The use of routine tracking data to measure adherence maybe more pragmatic than using observational coders and more objective than self-reports.

PRACTICE IMPLICATIONS

In busy HIV clinics, MI training should focus on strategies most directly associated with increased provider competence.

Study Protocol: Multi-level Determinants of Implementation and Sustainment in the Education Sector

Evidence-based programs (EBPs) delivered in elementary schools show great promise in reducing risk for emotional and behavioral disorders (EBDs). However, efforts to sustain EBPs in school face barriers. Improving EBP sustainment thus represents a priority, but little research exists to inform the development of sustainment strategies. To address this gap, the Sustaining Evidenced-Based Innovations through Multi-level Implementation Constructs (SEISMIC) project will: (a) Determine if malleable individual, intervention, and organizational factors predict EBP treatment fidelity and modifications during implementation, sustainment, or both; (b) Assess the impact of EBP fidelity and modifications on child outcomes during implementation and sustainment; and (c) Explore the mechanisms through which individual, intervention, and organizational factors influence sustainment outcomes. This protocol paper describes SEISMIC, which builds upon a federally-funded RCT evaluating BEST in CLASS, a teacher-delivered program for K-3rd grade children at risk for EBDs. The sample will include 96 teachers, 384 children, and 12 elementary schools. A multi-level, interrupted time series design will be used to examine the relationship between baseline factors, treatment fidelity, modifications, and child outcomes, followed by a mixed-method approach to elucidate the mechanisms that influence sustainment outcomes. Findings will be used to create a strategy to improve EBP sustainment in schools.

JUVENILE PROBATION OFFICER PERCEPTIONS OF PARENTAL INVOLVEMENT IN JUVENILE PROBATION AND WITH CONTINGENCY MANAGEMENT

Probation is a common sanction for youth substance users, and as such, juvenile probation officers (JPOs) shoulder much of the burden for treatment and rehabilitation. To improve youth outcomes and alleviate some of the burden, JPOs may seek parental involvement in the probation and substance use desistance processes. Using focus group data, we analyzed JPO perceptions of the role parents play in contingency management (CM)-an incentive system designed to produce and reward decreased substance use-and whether they perceived any value in CM. We found that most JPOs perceived parental involvement as critical to the success of both substance use treatment and CM for youth. Our findings also suggest JPOs found parental involvement in CM valuable given that CM was employed on nonstudy clients and future clients. This has implications for the practicality and sustainability of CM as a youth probation intervention.

Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery

Background

Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence.

Method

Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS.

Results

Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies.

Conclusions

As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.

Delinquency, Substance Use, and Risky Sexual Behaviors among Youth who are involved in the Justice System and Predominantly Reside in Rural Communities: Patterns and Associated Risk Factors

There is a significant gap in research examining the prevalence of problem behaviors among youth involved in the juvenile justice system in rural areas. The current study sought to address this gap by exploring the behavioral patterns of 210 youth who were on juvenile probation in predominantly rural counties and who were identified as having a substance use disorder. First, we examined the correlation among 7 problem behaviors representing different forms of substance use, delinquency, and sexual risk-taking and 8 risk factors related to recent service utilization, internalizing and externalizing difficulties, and social support networks. Then, we used latent class analysis (LCA) to identify distinct behavioral profiles based on the observed problem behaviors. LCA identified a 3-class model representing distinct groups labeled Experimenting (70%), Polysubstance Use + Delinquent Behaviors (24%), and Diverse Delinquent Behaviors (6%). Finally, we assessed differences (i.e., ANOVA, χ2) in each risk factor across the behavioral profiles. Important similarities and differences in the association among the problem behaviors, behavioral profiles, and the risk factors were revealed. These findings underscore the need for an interconnected behavioral health model within rural juvenile justice systems that is able to address youths' multidimensional needs including criminogenic, behavioral, and physical health needs.

Performance of a Supervisor Observational Coding System and an Audit and Feedback Intervention

Workplace-based clinical supervision is common in community based mental health care for youth and families and could be a leveraged to scale and improve the implementation of evidence-based treatment (EBTs). Accurate methods are needed to measure, monitor, and support supervisor performance with limited disruption to workflow. Audit and Feedback (A&F) interventions may offer some promise in this regard. The study-a randomized controlled trial with 60 clinical supervisors measured longitudinally for 7 months-had two parts: (1) psychometric evaluation of an observational coding system for measuring adherence and competence of EBT supervision and (2) evaluation of an experimental Supervisor Audit and Feedback (SAF) intervention on outcomes of supervisor adherence and competence. All supervisors recorded and uploaded weekly supervision sessions for 7 months, and those in the experimental condition were provided a single, monthly web-based feedback report. Psychometric performance was evaluated using measurement models based in Item Response Theory, and the effect of the SAF intervention was evaluated using mixed-effects regression models. The observational instrument performed well across psychometric indicators of dimensionality, rating scale functionality, and item fit; however, coder reliability was lower for competence than for adherence. Statistically significant A&F effects were largely in the expected directions and consistent with hypotheses. The observational coding system performed well, and a monthly electronic feedback report showed promise in maintaining or improving community-based clinical supervisors' adherence and, to a lesser extent, competence. Limitations discussed include unknown generalizability to the supervision of other EBTs.

Randomized trial of a diversion program for property offenders with drug use

PURPOSE

This paper reports findings from a randomized controlled trial of a front-end diversion program for prison-bound individuals with property crime convictions, concurrent substance use problems, and no prior violent crime convictions.

METHODS

Two counties in Oregon participated in the trial, labeled "County A" and "County B." Across counties, 272 individuals (mean age = 32.7 years; 67.6% male) were recruited and randomized to receive either the diversion program (Senate Bill 416 [SB416]) or probation as usual (PAU). The primary outcome was recidivism, defined as any arrest, conviction, or incarceration for a new crime within three years of diversion from prison.

RESULTS

In County A, SB416 did not outperform PAU on any recidivism outcome. However, in County B, SB416 yielded significantly greater improvements across various configurations of the arrest, conviction, and incarceration outcomes, relative to PAU.

CONCLUSIONS

SB416 can yield reduced recidivism when implemented in a setting like County B, which when compared to County A, had fewer justice system resources and a limited history of cross-system collaboration. More research on SB416 is needed, including an examination of its mechanisms of change and its cost-effectiveness relative to standard criminal justice system processing.

Improving the feasibility of fidelity measurement for community-based quality assurance: Partial- versus full-session observations of supervisor adherence and competence

Background

Clinical supervision is a common quality assurance method for supporting the implementation and sustainment of evidence-based interventions (EBIs) in community mental health settings. However, assessing and supporting supervisor fidelity requires efficient and effective measurement methods. This study evaluated two observational coding approaches that are potentially more efficient than coding full sessions: a randomly selected 15-min segment and the first case discussion of the session.

Method

Data were leveraged from a randomized trial of an Audit and Feedback (A&F) intervention for supervisor Adherence and Competence. Supervisors ( N = 57) recorded and uploaded weekly group supervision sessions for 7 months, with one session observationally coded each month ( N = 374). Of the coded sessions, one was randomly selected for each supervisor, and a random 15-min segment was coded. Additionally, the first case discussion was coded for the full sample of sessions.

Results

Across all models (and controlling for the proportion of the session covered by the partial observation), Adherence and Competence scores from partial observations were positively and significantly associated with scores from full sessions. In all cases, partial observations were most accurate when the level of Adherence and Competence was moderate. At lower levels, partial observations were underestimates, and at higher levels, they were overestimates.

Conclusions

The results suggest that efficient observational measurement can be achieved while retaining a general level of measurement effectiveness. Practically, first-case discussions are easier to implement, whereas 15-min segments have fewer potential threats to validity. Evaluation of resource requirements is needed, along with determining whether A&F effects are retained if feedback is based on partial observations. Nevertheless, more efficient observational coding could increase the feasibility of routine fidelity monitoring and quality assurance strategies, including A&F, which ultimately could support the implementation and sustainment of effective supervision practices and EBIs in community practice settings. Plain Language Summary: When delivering evidence-based mental health interventions in community-based practice settings, a common quality assurance method is clinical supervision. To support supervisors, assessment methods are needed, and those methods need to be both efficient and effective. Ideally, supervision sessions would be recorded, and trained coders would rate the supervisor’s use of specific strategies. In most settings, though, this requires too many resources. The present study evaluated a more efficient approach. The data came from an existing randomized trial of an Audit and Feedback intervention for enhancing supervisor Adherence and Competence. This included 57 supervisors and 374 sessions across seven months of monitoring. Instead of rating full supervision sessions, a more efficient approach was to have coders rate partial sessions. Two types of partial observations were considered: a randomly selected 15-minute segment of the session and the first case discussion of the session. The aim was to see if partial observations and full observations led to similar conclusions about Adherence and Competence. In all cases, they did. The scores were most similar for sessions with moderate levels of Adherence and Competence. If Adherence and Competence were low, partial observations were underestimates, but if they were high, partial observations were overestimates. Observing partial sessions is more efficient, but in terms of accuracy, the benefits and limitations should be evaluated in light of how the scores will be used. Additionally, future research should consider whether Audit and Feedback interventions have the same effect if feedback is based on observations of partial sessions.

Motivations for Prescription Drug Misuse Related to Mental Health Problems in Adults

BACKGROUND

Prescription drug misuse (PDM) is a significant public health problem associated with mental health symptoms.

OBJECTIVES

This project investigates the connections between PDM motivations and mental health to inform intervention efforts.

METHODS

Using nationally representative adult data from the 2016-2018 National Survey on Drug Use and Health (N = 128,205; 53% female) this project investigated which motivations for misuse are related to past-year mental health problems including any mental illness, serious mental illness, major depressive episode, and suicidal thoughts. Complex samples logistic regression models of the main motivation of PDM for each mental health problem were conducted separately for each prescription drug class (i.e., opioids, tranquilizers, sedatives, and stimulants) while controlling for demographic characteristics.

RESULTS

Adults that reported PDM were more likely than those with no PDM to endorse past year mental health problems. Compared to those that reported PDM of other medications, those misusing prescription opioids and tranquilizers to help with emotions and misusing sedatives to "relax or relieve tension" were more likely to have all categories of mental health problems. Those that misused prescription stimulants to "help study" had lower odds of all mental health problems.

CONCLUSIONS

While there were differences based on prescription drug class, a range of motivations increased adults' likelihood to have mental health problems and common themes were found across drug classes. While causality is still undetermined, prevention and intervention efforts that are multifaceted and individualized, while broadly providing adults with other ways to cope with negative emotions are likely to help reduce PDM.

Misunderstanding and Sensemaking Among Juvenile Probation Officers Working with Evidence-Based Practices

Evidence-based practices and programs (EBPs) have been adopted in juvenile probation agencies nationwide to maximize the number of successful probation cases. However, various pragmatic studies have found that JPOs are not yielding the expected benefits when compared to efficacy studies (Lipsey et al., 2010; Taxman & Belenko, 2011). Using focus group and survey data, the current study sought to increase our understanding of the gap between pragmatic and efficacy studies in juvenile probation settings by examining JPOs' perceptions and utilization of EBPs. The findings suggest that JPOs are misunderstanding how to use EBPs in daily practice, leaving them with negative perceptions of EBPs. Implications for improving JPO understanding and use of EBPs are discussed.

Meeting the Needs of Families Involved in the Child Welfare System for Parental Substance Abuse: Outcomes From an Effectiveness Trial of the Families Actively Improving Relationships Program

Limited evidence-based practices exist to address the unique treatment needs of families involved in the child welfare system with parental substance abuse. Specifically, parental opioid and methamphetamine abuse have increased over the last decade, with associated increases of families reported to the child welfare system. The Families Actively Improving Relationships (FAIR) program was developed to address the complexities of these families. Evidence-based strategies to address the interrelated needs of parents—including substance abuse and mental health treatment, parent skills training, and supportive case management to improve access to ancillary needs—are integrated in an intensive community outpatient program. This study examined the clinical effectiveness of FAIR when delivered in a Medicaid billable outpatient clinic. Parents (n = 99) were randomized either to the immediate FAIR condition or to the Waitlist (WL) condition, using a dynamic wait-listed design, with all parents provided the opportunity to eventually receive FAIR. Outcomes show statistically and clinically significant reductions in parental opioid and methamphetamine use, mental health symptoms, and parenting risk, and improvements in stability in parents receiving FAIR. Providing services to families who require travel in excess of 20 miles for sessions has challenging implications for program costs under a Medicaid structure. Study outcomes highlight the need for policies to support funding of intensive family-based programs.

Are therapist adherence and competence related to clinical outcomes in cognitive-behavioral treatment for youth anxiety?

INTRODUCTION

Studies have found that psychological treatments produce positive clinical outcomes for many problems experienced by youth. However, there is limited research on whether therapist adherence and competence in delivering these treatments are related to differential clinical outcomes.

METHOD

We examined the relationship of therapist adherence and competence to clinical outcomes in a sample of 51 youth aged 7-14 years (M age = 10.36, SD = 1.90; 86.3% white; 60.8% male) treated for anxiety disorders with a manualized individual cognitive-behavioral therapy. Adherence and competence were measured via coding of recorded treatment session content and outcomes were measured by caregiver and youth report across multiple timepoints. We used two-level mixed-effects regression models to test the degree to which adherence and competence predicted differential youth clinical outcomes.

RESULTS

Across multiple caregiver- and child-reported symptom and diagnostic outcomes, we found no statistically significant relationship between adherence or competence and clinical outcomes.

DISCUSSION

Although there was variability in both treatment integrity and clinical outcome, neither adherence to nor competence in youth anxiety treatment was related to clinical outcomes for youth with anxiety disorders treated with individual cognitive-behavioral treatment (CBT) in a research clinic-based efficacy trial. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Predictors of substance use in a clinical sample of youth seeking treatment for Trauma-related mental health problems

Child maltreatment and traumatic events are well established risk factors for adolescent substance use problems, but little is known about the unique contributions of etiological factors on trauma-exposed youths' pre-treatment substance use in clinical settings. This study examined associations between substance use and risk and protective factors measured across multiple ecological levels among a unique sample of youth seeking treatment for trauma-related mental health problems in child advocacy centers. Participants were adolescents (N = 135; 85% female; 60% white, 31% black) aged 13-17 years (M = 15.4) with ≥ 1 experience of child maltreatment or other interpersonal violence, current substance use, and ≥5 PTSD symptoms. Youth and caregivers completed validated questionnaires and clinical interviews at a pre-treatment assessment in a randomized controlled trial of a treatment for co-occurring traumatic stress and substance use. Negative binomial regression models identified different patterns of risk and protective factors for alcohol and cannabis. Clinical implications of these results are discussed, including the potential targets for integrated psychotherapies that address co-occurring substance use and traumatic stress in youth.

Juvenile probation officers' perceptions on youth substance use varies from task-shifting to family-based contingency management

The majority of justice-involved youth have problems with substance use, but juvenile justice agencies face numerous barriers to providing evidence-based treatments for these youth. Task-shifting is one strategy for increasing access to such treatments. That is, training juvenile probation officers (JPOs) to deliver substance use treatments, such as contingency management (CM) could improve youths' motivation and behavioral outcomes. However, probation traditionally emphasizes sanctions over incentives, so JPOs must alter their perspectives to accept protocols such as CM for substance use. Using mixed focus group and survey methods at baseline and one year later, this randomized study examined heretofore unstudied JPO perceptions during a task-shifting experiment in which JPOs were asked to start delivering CM for youth substance use, compared to a control group of JPOs who did not change their practices. At baseline, JPOs expressed a perception of hopelessness about their work with substance-using youth and their parents, but they generally held positive views toward use of tangible incentives. One year after randomization to participate in CM training and delivery, JPO perceptions changed positively about working with youth and their parents, substance use programs and resources, and whether they believed tangible incentive programs were worthwhile. Over the same time, there was a perceptual stasis in hopelessness for JPOs randomized to deliver probation services as usual, and there was degradation in their previously positive perception toward tangible incentives. The study advances thinking regarding tools that JPOs can use for working with youth and families and the role that task-shifting can play in both increasing access to evidence-based treatments and improving attitudinal outcomes of JPOs.

Community-based randomized controlled trial of psychological first aid with crime victims

OBJECTIVE

The first randomized controlled trial of psychological first aid (PFA) was conducted, using crime victims as participants. For study Aim 1, investigators tested whether paraprofessional victim advocates could be trained to deliver PFA to crime victims. For study Aim 2, investigators tested the effect of PFA delivery on victims' psychiatric (i.e., symptoms of PTSD, somatization, depression, anxiety, and substance use) and adaptive functioning outcomes.

METHOD

Two law enforcement agencies served as study sites. A dynamic wait-listed design included a phase when advocates at both sites delivered usual services (US) to victims, a phase when one site was randomly selected to deliver PFA while the other delivered US, and a phase when both sites delivered PFA. Across all phases, 172 crime victims (mean age = 36.4 years; 81% female) were recruited, and a battery assessed their psychiatric symptoms and adaptive functioning at baseline and 1, 2, and 4 months postbaseline.

RESULTS

From the US to PFA phases, advocates' PFA adherence (i.e., their delivery of PFA components) increased significantly. PFA did not outperform US with regard to improvement on victims' individual psychiatric and adaptive functioning outcomes. However, on a composite global functioning outcome created for this trial, PFA yielded significantly greater improvement relative to US.

CONCLUSION

Paraprofessional victim advocates have the capacity to deliver PFA. Conclusions regarding the effectiveness of PFA for crime victims vary depending on the nature of the scored outcome variable (individual vs. global), highlighting the importance of careful outcome measurement considerations in future research on PFA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Safety and Efficacy of Exposure-Based Risk Reduction Through Family Therapy for Co-occurring Substance Use Problems and Posttraumatic Stress Disorder Symptoms Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

No empirically supported treatments have been evaluated to address co-occurring substance use problems (SUP) and posttraumatic stress disorder (PTSD) symptoms among adolescents in an integrative fashion. This lack is partially owing to untested clinical lore suggesting that delivery of exposure-based PTSD treatments to youth with SUP might be iatrogenic.

OBJECTIVE

To determine whether an exposure-based, integrative intervention for adolescents with SUP and PTSD symptoms-risk reduction through family therapy (RRFT)-resulted in improved outcomes relative to a treatment-as-usual (TAU) control condition consisting primarily of trauma-focused cognitive behavioral therapy.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled 124 participants who were recruited from November 1, 2012, through January 30, 2017. Adolescents (aged 13-18 years) who engaged in nontobacco substance use at least once during the past 90 days, experienced at least 1 interpersonal traumatic event, and reported 5 or more PTSD symptoms were enrolled. Blinded assessments were collected at baseline and at 3, 6, 12, and 18 months after baseline. Recruitment and treatment took place in community-based child advocacy centers in the Southeastern United States. Data were analyzed from August 2 through October 4, 2018, and were based on intention to treat.

INTERVENTIONS

Participants were randomized to receive RRFT (n = 61) or TAU (n = 63).

MAIN OUTCOMES AND MEASURES

Primary outcomes focused on number of nontobacco substance-using days measured with the timeline follow-back method and PTSD symptom severity using the UCLA (University of California, Los Angeles) PTSD Reaction Index for DSM-IV completed by adolescents and caregivers. Secondary outcomes focused on marijuana, alcohol, and polysubstance use and PTSD criterion standard (re-experiencing, avoidance, and hyperarousal) symptom severity.

RESULTS

In all, 124 adolescents (mean [SD] age, 15.4 [1.3] years; 108 female [87.1%]) were randomized. For primary outcomes relative to TAU, RRFT yielded significantly greater reductions in substance-using days from baseline to month 12 (event rate [ER], 0.28; 95% CI, 0.12-0.65) and month 18 (ER, 0.10; 95% CI, 0.04-0.24). Significant reductions in PTSD symptoms were observed within groups for RRFT from baseline to months 3 (β = -9.25; 95% CI, -12.95 to -5.55), 6 (β = -16.63; 95% CI = -20.40 to -12.87), 12 (β = -17.51; 95% CI, -21.62 to -13.40), and 18 (β = -19.02; 95% CI, -23.07 to -14.96) and for TAU from baseline to months 3 (β = -9.62; 95% CI, -13.16 to -6.08), 6 (β = -13.73; 95% CI, -17.43 to -10.03), 12 (β = -15.53; 95% CI, -19.52 to -11.55), and 18 (β = -13.88; 95% CI, -17.69 to -10.09); however, between-group differences were not observed.

CONCLUSIONS AND RELEVANCE

In this study, RRFT and TAU demonstrated within-group improvements in SUP and PTSD symptoms, with greater improvement for substance use and PTSD avoidance and hyperarousal symptoms among adolescents randomized to RRFT compared with TAU. No evidence of the worsening of SUP was observed in either condition. These results suggest that this exposure-based treatment is safe, feasibly delivered by community-based clinicians, and offers an effective approach to inform clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01751035.

Burnout and Mental Health Stigma Among Juvenile Probation Officers: The Moderating Effect of Participatory Atmosphere

Despite high rates of mental health problems among juvenile justice-involved youth, mental health stigma among juvenile probation officers (JPOs) is under-studied. This cross-sectional study examined effects of job burnout and workplace participatory atmosphere on mental health stigma among JPOs across Indiana (n = 226). Participatory atmosphere moderated the relationship between JPO burnout-related cynicism and mental health stigma (interaction β = - 0.14, p = .04); burnout was related to greater mental health stigma at low levels of participatory atmosphere. Findings suggest participatory atmosphere mitigates effects of burnout on mental health stigma among JPOs. Organizational-level interventions might help to reduce mental health stigma and combat negative effects from burnout among JPOs.

Capacity of juvenile probation officers in low-resourced, rural settings to deliver an evidence-based substance use intervention to adolescents

Substance use is a major public health problem with a host of negative outcomes. Justice-involved youth have even higher risks and lack access to evidence-based interventions, particularly in rural communities. Task-shifting, or redistribution of tasks downstream to an existing workforce with less training, may be an innovative strategy to increase access to evidence-based interventions. Initial findings are presented from a services research trial conducted primarily in rural communities in which an existing workforce, juvenile probation/parole officers (JPOs), were randomized either to learn and deliver contingency management (CM) or to continue delivering probation services as usual (PAU). This study used the prevailing version of CM for adolescents, that is, family-based with behavior modification and cognitive behavioral components. Data included JPOs' self-reports, as well as audio-recorded youth/family sessions with JPOs rated by expert and trained observational coders. Data also included ratings from a comparison study in which therapists were trained and supervised by experts to deliver CM to justice-involved youth/families. Results showed JPOs can feasibly incorporate CM into their services. When adherence of CM JPOs was compared against CM therapists, JPOs delivered significantly more cognitive behavioral components of CM and similar levels of behavior modification components of CM. These findings suggest that JPOs can be leveraged to provide evidence-based substance use interventions like CM in similar, or even greater, capacities to clinically trained therapists. This task-shifting approach could dramatically expand service access for these high-risk youth, particularly in rural areas where substance use services are limited or nonexistent. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Testing a Motivational Interviewing Implementation Intervention in Adolescent HIV Clinics: Protocol for a Type 3, Hybrid Implementation-Effectiveness Trial

Background

Motivational interviewing (MI) has been shown to effectively improve self-management for youth living with HIV (YLH) and has demonstrated success across the youth HIV care cascade—currently, the only behavioral intervention to do so. Substantial barriers prevent the effective implementation of MI in real-world settings. Thus, there is a critical need to understand how to implement evidence-based practices (EBPs), such as MI, and promote behavior change in youth HIV treatment settings as risk-taking behaviors peak during adolescence and young adulthood.

Objective

This study aims to describe the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) protocol of a tailored MI (TMI) implementation-effectiveness trial (ATN 146 TMI) to scale up an EBP in multidisciplinary adolescent HIV settings while balancing flexibility and fidelity. This protocol is part of the Scale It Up program described in this issue.

Methods

This study is a type 3, hybrid implementation-effectiveness trial that tests the effect of TMI on fidelity (MI competency and adherence to program requirements) while integrating findings from two other ATN protocols described in this issue—ATN 153 Exploration, Preparations, Implementation, Sustainment and ATN 154 Cascade Monitoring. ATN 153 guides the mixed methods investigation of barriers and facilitators of implementation, while ATN 154 provides effectiveness outcomes. The TMI study population consists of providers at 10 adolescent HIV care sites around the United States. These 10 clinics are randomly assigned to 5 blocks to receive the TMI implementation intervention (workshop and trigger-based coaching guided by local implementation teams) utilizing the dynamic wait-listed controlled design. After 12 months of implementation, a second randomization compares a combination of internal facilitator coaching with the encouragement of communities of practice (CoPs) to CoPs alone. Participants receive MI competency assessments on a quarterly basis during preimplementation, during the 12 months of implementation and during the sustainment period for a total of 36 months. We hypothesize that MI competency ratings will be higher among providers during the TMI implementation phase compared with the standard care phase, and successful implementation will be associated with improved cascade-related outcomes, namely undetectable viral load and a greater number of clinic visits among YLH.

Results

Participant recruitment began in August 2017 and is ongoing. As of mid-May 2018, TMI has 150 active participants.

Conclusions

This protocol describes the underlying theoretical framework, study design, measures, and lessons learned for TMI, a type 3, hybrid implementation-effectiveness trial, which has the potential to scale up MI and improve patient outcomes in adolescent HIV settings.

Trial Registration

ClinicalTrials.gov NCT03681912; https://clinicaltrials.gov/ct2/show/NCT03681912 (Archived by WebCite at http://www.webcitation.org/754oT7Khx)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11200

Therapist perception of treatment outcome: Evaluating treatment outcomes among youth with antisocial behavior problems

Effective evaluation of treatment requires the use of measurement tools producing reliable scores that can be used to make valid decisions about the outcomes of interest. Therapist-rated treatment outcome scores that are obtained within the context of empirically supported treatments (ESTs) could provide clinicians and researchers with data that are easily accessible and complimentary to existing instrumentation. We examined the psychometric properties of scores from the Therapist Perception of Treatment Outcome: Youth Antisocial Behavior (TPTO:YAB), an instrument developed to assess therapist judgments of treatment success among families participating in an EST, Multisystemic Therapy (MST), for youth with antisocial behavior problems. Data were drawn from a longitudinal study of MST. The initial 20-item TPTO:YAB was completed by therapists of 111 families at midtreatment and 163 families at treatment termination. Rasch model dimensionality analyses provided evidence for 2 dimensions reflecting youth- and caregiver-related aspects of treatment outcome, although a bifactor analyses suggested that these dimensions reflected a single more general construct. Rasch analyses were also used to assess item and rating scale characteristics and refine the number of items. These analyses suggested items performed similarly across time and that scores reflect treatment outcome in similar ways at mid and posttreatment. Multilevel and zero-order analyses provided evidence for the validity of TPTO:YAB scores. TPTO:YAB scores were moderately correlated with scores of youth and caregiver behaviors targeted in treatment, adding support to its use as a treatment outcome measurement instrument.

Defining and Evaluating Fidelity at the Program Level in Psychosocial Treatments

One challenge to research on the implementation of effective psychosocial treatments is how to define and measure fidelity at the program level. The purpose of this study was to evaluate an approach to defining, measuring, and observing over time fidelity at the program level for Multisystemic Therapy (MST). For this study, program fidelity was conceptualized as a program’s performance on several key areas identified in the literature as contributing to sustainability. A composite index, the MST Program Performance Index (PPI), was developed using data from the MST quality assurance system. The PPI included indicators of treatment adherence, treatment completion, program operations, program capacity, clinical supervisor leadership, and stakeholder relationships. A PPI score was calculated for 496 MST teams every 6 months for a two year period, during which time, the teams served over 25,000 young people. The predictive validity of the PPI score was supported by both client- and team-level outcomes. Specifically, youth treated by teams with lower PPI scores were more likely to be rearrested during their course of treatment. Likewise, teams with lower PPI scores were more likely to close during the time period covered by the study. Analysis of scores over the two year period showed substantial within-team variability in the PPI; however, the scores did not follow a linear pattern of change. In summary, preliminary evidence suggests the PPI may be a useful tool to index program-level fidelity for comparative purposes and as an additional tool for a decision support system.

Evaluating training methods for transporting contingency management to therapists

The effects of three increasingly intensive training methods on therapist use, knowledge, and implementation adherence of contingency management (CM) with substance abusing adolescents were evaluated. Ten public sector substance abuse or mental health provider organizations were randomized to one of three training conditions: workshop and resources (WS+), WS+and computer assisted training (WS+/CAT), or WS+/CAT and supervisory support (WS+/CAT/SS). Across conditions, 161 therapists participated in the training experiences, and measures were obtained at baseline and 2-month intervals for 12 months following workshop participation. Across training conditions, therapists reported increased CM use, knowledge, and implementation adherence through the 12-month follow-up. The findings show that community-based practitioners are amenable to the adoption of evidence-based treatments when provided access to useful resources. Moreover, high quality workshops in combination with resource access can increase knowledge of the evidence-based treatment and might enhance intervention adherence to a level needed to improve youth outcomes.

RCT of a promising vocational/employment program for high-risk juvenile offenders

Juvenile offenders with substance use problems are at high risk for deleterious long-term outcomes. This study evaluated the capacity of a promising vocational and employment training program in the building sector (i.e., Community Restitution Apprenticeship-Focused Training, CRAFT) to mitigate such outcomes through enhanced employment and education. Participants were 97 high-risk juvenile offenders (mean age=15.8 years) randomized to CRAFT versus education as usual (EAU) intervention conditions. Multi-method procedures measured employment, education, substance use, mental health, and criminal outcomes through a 30-month post-baseline follow-up. CRAFT was significantly more effective than EAU at increasing rates of youth employment and GED attendance. Intervention effects were not observed, however, for months employed, hours worked, or hourly wage. Measures of youth substance use, mental health symptoms, and criminal activity showed no favorable or iatrogenic effects. The potential of CRAFT was modestly supported, and suggestions were made for future research.

Comparison of youth, caregiver, therapist, trained, and treatment expert raters of therapist adherence to a substance abuse treatment protocol

OBJECTIVE

This study evaluated the accuracy of youth, caregiver, therapist, and trained raters relative to treatment experts on ratings of therapist adherence to a substance abuse treatment protocol for adolescents.

METHOD

Adherence ratings were provided by youth and caregivers in an ongoing trial evaluating a Contingency Management (CM) intervention for youth in juvenile drug court. These ratings were compared to those provided by therapists and trained raters, and each rater type was compared to ratings provided by CM treatment experts. Data were analyzed using item-response-theory-based Many-Facet Rasch Models.

RESULTS

Relative to treatment experts, youth and caregivers were significantly more likely to endorse the occurrence of CM components. In contrast, therapists and trained raters were much more consistent with treatment experts. In terms of practical significance, youth and caregivers each had a 97% estimated probability of indicating that a typical treatment component had occurred. By comparison, the probability was 31%, 19%, and 26% for therapists, trained raters, and treatment experts, respectively.

CONCLUSIONS

Youth and caregivers were highly inaccurate relative to treatment experts, whereas, therapists and trained raters were generally consistent with treatment experts. The implications of these findings for therapist adherence measurement are considered.

System-level effects of integrating a promising treatment into juvenile drug courts

This study examined the system-level effects of implementing a promising treatment for adolescent substance abuse in juvenile drug courts (JDCs). Six JDCs were randomized to receive training in the experimental intervention (contingency management-family engagement [CM-FAM]) or to continue their usual services (US). Participants were 104 families served by the courts, 51 therapists, and 74 JDC stakeholders (e.g., judges, prosecutors, defense attorneys). Assessments included repeated measurements of CM-FAM implementation by therapists and therapist and stakeholder perceptions of incentive-based interventions and organizational characteristics. Results revealed greater use of CM and family engagement techniques among CM-FAM relative to US therapists. In addition, therapists and stakeholders in the CM-FAM condition reported more favorable attitudes toward the use of incentives and greater improvement on several domains of organizational functioning relative to US counterparts. Taken together, these findings suggest that JDC professionals are amenable to the adoption and implementation of a treatment model that holds promise for improving youth outcomes.

Multisystemic therapy for poorly adherent youth with HIV: results from a pilot randomized controlled trial

Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care. Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load [VL] and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within- and between-groups differences in the slopes of these outcomes. Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant VL reductions following the start of treatment. There was also some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition. MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify the mechanisms of action are important next steps.

Taking Effective Treatments to Scale: Organizational Effects on Outcomes of Multisystemic Therapy for Youth with Co-occurring Substance Use

A prospective multi-site study examined organizational climate and structure effects on the behavior and functioning of delinquent youth with and without co-occurring substance treated with an evidence-based treatment for serious antisocial behavior (i.e., Multisystemic Therapy). Participants were 1979 youth treated by 429 therapists across 45 provider organizations in North America. Results of Mixed Effects Regression Models showed some aspects of climate and structure had no effects, some had similar effects, and some had slightly differential and sometimes counter-intuitive effects on the outcomes of these youth. Implications are considered for research to increase the array and availability of effective treatments for youth with co-occurring substance use across service sectors.

Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.

Enhancing the effectiveness of juvenile drug courts by integrating evidence-based practices

OBJECTIVE

The primary purpose of this study was to test a relatively efficient strategy for enhancing the capacity of juvenile drug courts (JDC) to reduce youth substance use and criminal behavior by incorporating components of evidence-based treatments into their existing services.

METHOD

Six JDCs were randomized to a condition in which therapists were trained to deliver contingency management in combination with family engagement strategies (CM-FAM) or to continue their usual services (US). Participants included 104 juvenile offenders (average age = 15.4 years; 83% male; 57% White, 40% African American, 3% Biracial). Eighty-six percent of the youths met criteria for at least 1 substance use disorder, and co-occurring psychiatric diagnoses were highly prevalent. Biological and self-report measures of substance use and self-reported delinquency were assessed from baseline through 9 months postrecruitment.

RESULTS

CM-FAM was significantly more effective than US at reducing marijuana use, based on urine drug screens, and at reducing both crimes against persons and property offenses. Such favorable outcomes, however, were not observed for the self-report measure of substance use. Although some variation in outcomes was observed between courts, the outcomes were not moderated by demographic characteristics or co-occurring psychiatric disorders.

CONCLUSIONS

The findings suggest that JDC practices can be enhanced to improve outcomes for participating juvenile offenders. A vehicle for promoting such enhancements might pertain to the development and implementation of program certification standards that support the use of evidence-based interventions by JDCs. Such standards have been fundamental to the successful transport of evidence-based treatments of juvenile offenders.

Adherence Measurement in Treatments for Disruptive Behavior Disorders: Pursuing Clear Vision through Varied Lenses

To extend the reach, transparency, and accountability for the implementation and outcomes of effective treatments in routine care, more clarity is needed about what happens in treatment. We attempt to (a) clarify terminology to describe and measure psychological treatment, and (b) consider what treatment adherence instruments can tell us about what happens in treatment. We reviewed the content of 11 adherence instruments for 14 evidence-based treatments for disruptive behavior problems in youth identified in an ongoing review of adherence measurement methods used in psychosocial treatment studies from 1980 - 2008. Item number, content, and level of detail varied widely. Implications are considered for the definition of effective treatments and design and testing of strategies to measure and monitor their delivery.

Toward the effective and efficient measurement of implementation fidelity

Implementation science in mental health is informed by other academic disciplines and industries. Conceptual and methodological territory charted in psychotherapy research is pertinent to two elements of the conceptual model of implementation posited by Aarons and colleagues (2010)--implementation fidelity and innovation feedback systems. Key characteristics of scientifically validated fidelity instruments, and of the feasibility of their use in routine care, are presented. The challenges of ensuring fidelity measurement methods are both effective (scientifically validated) and efficient (feasible and useful in routine care) are identified as are examples of implementation research attempting to balance these attributes of fidelity measurement.

Ethnic Similarity, Therapist Adherence, and Long-Term Multisystemic Therapy Outcomes

The current study investigated relations among ethnic similarity in caregiver-therapist pairs of youth participating in Multisystemic Therapy, therapist adherence, and youth long-term behavioral and criminal outcomes. Participants were 1979 youth and families treated by 429 therapists across provider organizations in 45 sites. Relations were found, independently, and in the presence of ethnic similarity, between adherence and reductions in youth Externalizing and Internalizing behavior problems 1-year post-treatment and youth criminal charges 4 years post-treatment. Relations between ethnic similarity and outcomes were found only for reductions in youth Externalizing behavior problems and not when adherence was included in the model. Adherence ratings were higher, however, in ethnically similar caregiver-therapist pairs, and evidence was found that this increased adherence predicted slightly better outcomes for youth. Implications for future research and clinical practice are considered.

Predicting nonresponse to juvenile drug court interventions

Using data from a recent randomized clinical trial involving juvenile drug court (JDC), youth marijuana use trajectories and the predictors of treatment nonresponse were examined. Participants were 118 juvenile offenders meeting diagnostic criteria for substance use disorders assigned to JDC and their families. Urine drug screen results were gathered from weekly court visits for 6 months, and youth reported their marijuana use over 12 months. Semiparametric mixture modeling jointly estimated and classified trajectories of both marijuana use indices. Youth were classified into responder versus nonresponder trajectory groups based on both outcomes. Regression analyses examined pretreatment individual, family, and extrafamilial predictors of nonresponse. Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups. Findings have implications for the design of interventions to improve JDC outcomes.

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy

OBJECTIVE

A randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth.

METHOD

A 2 x 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9-17 years included the Child Behavior Checklist and out-of-home placements.

RESULTS

A multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%).

CONCLUSIONS

Two-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

Clinical supervision in treatment transport: effects on adherence and outcomes

This nonexperimental study used mixed-effects regression models to examine relations among supervisor adherence to a clinical supervision protocol, therapist adherence, and changes in the behavior and functioning of youths with serious antisocial behavior treated with an empirically supported treatment (i.e., multisystemic therapy [MST]) 1 year posttreatment. Participants were 1,979 youths and families treated by 429 clinicians across 45 provider organizations in North America. Four dimensions of clinical supervision were examined. Mixed-effects regression model results showed that one dimension, supervisor focus on adherence to treatment principles, predicted greater therapist adherence. Two supervision dimensions, Adherence to the Structure and Process of Supervision and focus on Clinician Development, predicted changes in youth behavior. Conditions required to test hypothesized mediation by therapist adherence of supervisor adherence effects on youth outcomes were not met. However, direct effects of supervisor and therapist adherence were observed in models including both of these variables.

Mediators of change for multisystemic therapy with juvenile sexual offenders

The mediators of favorable multisystemic therapy (MST) outcomes achieved at 12 months postrecruitment were examined within the context of a randomized effectiveness trial with 127 juvenile sexual offenders and their caregivers. Outcome measures assessed youth delinquency, substance use, externalizing symptoms, and deviant sexual interest/risk behaviors; hypothesized mediators included measures of parenting and peer relations. Data were collected at pretreatment, 6 months postrecruitment, and 12 months postrecruitment. Consistent with the MST theory of change and the small extant literature in this area of research, analyses showed that favorable MST effects on youth antisocial behavior and deviant sexual interest/risk behaviors were mediated by increased caregiver follow-through on discipline practices as well as decreased caregiver disapproval of and concern about the youth's bad friends during the follow-up. These findings have important implications for the community-based treatment of juvenile sexual offenders.

Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial

Despite the serious and costly problems presented by juvenile sexual offenders, rigorous tests of promising interventions have rarely been conducted. This study presents a community-based effectiveness trial comparing multisystemic therapy (MST) adapted for juvenile sexual offenders with services that are typical of those provided to juvenile sexual offenders in the United States. Youth were randomized to MST (n = 67) or treatment as usual for juvenile sexual offenders (TAU-JSO; n = 60). Outcomes through 12 months postrecruitment were assessed for problem sexual behavior, delinquency, substance use, mental health functioning, and out-of-home placements. Relative to youth who received TAU-JSO, youth in the MST condition evidenced significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements. The findings suggest that family- and community-based interventions, especially those with an established evidence-base in treating adolescent antisocial behavior, hold considerable promise in meeting the clinical needs of juvenile sexual offenders.

Statewide adoption and initial implementation of contingency management for substance-abusing adolescents

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted.

Long-term youth criminal outcomes in MST transport: the impact of therapist adherence and organizational climate and structure

This study investigated relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior (i.e., Multisystemic Therapy), organizational climate and structure, and youth criminal charges on average 4 years posttreatment. Participants were 1,979 youth and families treated by 429 therapists across 45 provider organizations. Results showed therapist adherence predicted significantly lower rates of youth criminal charges independently and in the presence of organizational variables. Therapist perceptions of job satisfaction and opportunities for growth and advancement relative to the organizational average predicted youth criminal charges, as did organizational average levels of participation in decision making. These associations washed out in the presence of adherence, despite the fact that job satisfaction and growth and advancement were associated with adherence.

Therapist adherence and organizational effects on change in youth behavior problems one year after multisystemic therapy

The current study investigated the relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior (i.e., Multisystemic Therapy), organizational climate and structure, and improvement in youth behavior problems one-year post treatment. Participants were 1979 youth and families treated by 429 therapists across 45 provider organizations in North America. Hierarchical Linear Modeling (HLM) results showed therapist adherence predicted improvement in youth behavior. Two structure variables and one climate variable predicted changes in youth behavior, and the climate variable also predicted therapist adherence. No statistical support for formal mediation of organizational effects through adherence was found, though examination of changes in parameter estimates suggest a possible interplay of organizational climate with adherence and youth behavior change.

Developing a Measure of Therapist Adherence to Contingency Management: An Application of the Many-Facet Rasch Model

A unique application of the Many-Facet Rasch Model (MFRM) is introduced as the preferred method for evaluating the psychometric properties of a measure of therapist adherence to Contingency Management (CM) treatment of adolescent substance use. The utility of psychometric methods based in Classical Test Theory was limited by complexities of the data, including: (a) ratings provided by multiple informants (i.e., youth, caregivers, and therapists), (b) data from separate research studies, (c) repeated measurements, (d) multiple versions of the questionnaire, and (e) missing data. Two dimensions of CM adherence were supported: adherence to Cognitive Behavioral components and adherence to Monitoring components. The rating scale performed differently for items in these subscales, and of 11 items evaluated, eight were found to perform well. The MFRM is presented as a highly flexible approach that can be used to overcome the limitations of traditional methods in the development of adherence measures for evidence-based practices.

Treatment outcome and criminal offending by youth with sexual behavior problems

Children and adolescents treated for general delinquency problems and rated by caregivers as having sexual behavior problems (SBP; N = 696) were compared with youth from the same sample with no sexual behavior problems (NSBP; N = 1,185). Treatment outcome through 12-months posttreatment and criminal offending through an average 48-month posttreatment were compared for both groups. It was hypothesized that both groups would improve over time; however, the SBP group would evidence greater psychopathology at follow-up, and these hypotheses were supported. It was further hypothesized that youth with SBP would not differ from youth with NSBP in rates of future sexual or nonsexual offenses. These hypotheses were also supported. SBP group membership was not a significant predictive factor in analyses modeling future offending (any) or future person offenses. Few youth in either group had sexual offenses. The importance of these findings for clinical and policy decision making is discussed.