Predictors of nonresponse and drop-out among children and adolescents receiving TF-CBT: investigation of client-, therapist-, and implementation factors.

BACKGROUND: There is a paucity of evidence about effective implementation strategies to increase treatment response and prevent drop-out among children receiving evidence-based treatment. This study examines patient, therapist, and implementation factors and their association to nonresponse and drop-out among youth receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). METHODS: Youth (n = 1240) aged 6-18 (M = 14.6) received TF-CBT delivered by 382 TF-CBT therapists at 66 clinics. Odds ratio analyses were used to investigate whether pretreatment child (age, gender, number of trauma experiences, post-traumatic stress symptoms (PTSS), therapist (education), and implementation strategy factors (high-low, low-low, low-high intensity therapist and leadership training respectively) or tele-mental health training during the Covid-19 pandemic are associated with nonresponse (above clinical PTSS level post-treatment) and drop-out (therapist-defined early termination). Fidelity checks were conducted to ensure that TF-CBT was used consistently. RESULTS: One fourth of the children (24.4%) were nonresponders and 13.3 percent dropped out. Exposure to three or more traumatic experiences were related to nonresponse and drop-out. Higher baseline PTSS was related to a higher probability of nonresponse. There was no effect of therapist education or child gender on nonresponse and drop-out, whereas children over 15 years had a higher likelihood of both. After controlling for baseline PTSS, the effect of age on nonresponse was no longer significant. Drop-out was related to fewer sessions, and most dropped out during the first two phases of TF-CBT. Fidelity was high throughout the different implementation phases. High-intensity therapist training was related to a lower probability of both nonresponse and drop-out, whereas low therapist and leadership training were related to a higher likelihood of both. Multivariate analysis revealed higher child age and higher PTSS baseline scores as significant predictors of nonresponse, and number of trauma experiences (> = 3) at baseline as the only predictor of drop-out. CONCLUSIONS: High-intensity therapist training seem key to prevent patient nonresponse and drop-out. Leadership training might positively affect both, although not enough to compensate for less intensive therapist training. More complex cases (higher PTSS and exposure to more traumas) predict nonresponse and drop-out respectively, which underscores the importance of symptom assessment to tailor the treatment. The lack of predictive effect of therapist education increases the utilization of TF-CBT. TRIAL REGISTRATION: Retrospectively registered in ClinicalTrials, ref. nr. NCT05248971.

A stepped-wedge randomized trial investigating the effect of the Leadership and Organizational Change for Implementation (LOCI) intervention on implementation and transformational leadership, and implementation climate.

BACKGROUND: This study evaluates the Leadership and Organizational Change for Implementation (LOCI) strategy and its effect on implementation leadership, transformational leadership, and implementation climate. METHODS: A stepped wedge cluster randomized study design enrolling 47 first-level leaders from child- and adult-specialized mental health clinics within Norwegian health trusts across three cohorts. All therapists (n = 790) received training in screening of trauma exposure and posttraumatic stress, and a subgroup of therapists (n = 248) received training in evidence-based treatment methods for posttraumatic stress disorder (PTSD). First-level leaders and therapists completed surveys at baseline, 4, 8-, 12-, 16-, and 20-months assessing leadership and implementation climate. General linear mixed-effects models were used to investigate whether the LOCI strategy would lead to greater therapist-rated scores on implementation leadership, transformational leadership, and implementation climate. RESULTS: After introducing the LOCI strategy, there was a significant increase in therapist-rated implementation and transformational leadership and implementation climate. The increase was sustained at all measurement time points compared to non-LOCI conditions, which demonstrated a steady decrease in scores before LOCI. CONCLUSIONS: The LOCI strategy can develop better transformational and implementation leadership skills and contribute to a more positive implementation climate, which may enhance successful EBP implementation. Thus, LOCI can help leaders create an organizational context conducive for effective EBP implementation. TRIAL REGISTRATION: Retrospectively registered: ClinicalTrials NCT03719651 , 25th of October 2018. The trial protocol can be accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417075/ .

Study protocol for a stepped-wedge implementation study investigating the intersectoral collaboration of implementering the TREAT INTERACT intervention for primary school teachers and the mhGAP for health care workers for child mental health promotion in Uganda.

BACKGROUND: Mental and neuropsychological disorders make up approximately 14% of the total health burden globally, with 80% of the affected living in low- and middle-income countries (LMICs) of whom 90% cannot access mental health services. The main objective of the TREAT INTERACT study is to adapt, implement, and evaluate the impact of a novel, intersectoral approach to prevent, identify, refer, and treat mental health problems in children through a user centred task-sharing implementation of the TREAT INTERACT intervention, inspired by the World Health Organization (WHO) Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for primary school staff in Mbale, Uganda. Health care personell will be trained in the mhGAP-IG. METHODS: This is a pragmatic mixed-methods hybrid Type II implementation-effectiveness study utilizing a co-design approach. The main study utilize a stepped-wedged trial design with six starting sequences, randomizing three schools to the intervention at each interval, while the remaining act as "controls". Other designs include a nested prospective cohort study, case control studies, cross-sectional studies, and qualitative research. Main participants' outcomes include teachers' mental health literacy, stigma, and violence towards the school children. Implementation outcomes include detection, reach, sustainability, and service delivery. Child and caregiver outcomes include mental health, mental health literacy, and help-seeking behaviour. DISCUSSION: Based on the results, we will develop sustainable and scalable implementation advice on mental health promotion and draft implementation guidelines in line with current WHO guidelines. This project will generate new knowledge on the structure, organization, delivery, and costs of mental health services in a LMIC setting, as well as new knowledge on the implementation and delivery of new health services. TRIAL REGISTRATION: ClinicalTrials, NCT06275672, 28.12.2023, retrospectively registered.

Individual-level associations between implementation leadership, climate, and anticipated outcomes: a time-lagged mediation analysis.

BACKGROUND: Leaders can improve implementation outcomes by developing an organizational climate conducive to the implementation of evidence-based practices (EBP). This study tested the lagged associations between individual-level perceptions of implementation leadership, implementation climate, and three anticipated implementation outcomes, that is EBP acceptability, appropriateness, and feasibility. METHODS: Screening tools and treatment methods for posttraumatic stress disorder were implemented in 43 Norwegian mental health services. A sample of 494 child and adult mental health care professionals (M = 43 years, 78% female) completed surveys addressing perceptions of first-level leaders' (n = 47) implementation leadership and their clinics' implementation climate. Single-level structural equation models estimating both direct, indirect, and total effects were used to investigate whether perceived implementation climate mediated the association between perceived implementation leadership and perceived acceptability, appropriateness, and feasibility of screening tools and treatment methods. RESULTS: Regarding the treatment methods, implementation leadership was associated with therapists' perceptions of acceptability, appropriateness, and feasibility. Implementation climate also mediated between implementation leadership and the outcomes. Regarding the screening tools, implementation leadership was not associated with the outcomes. However, implementation climate mediated between implementation leadership and therapists' perceptions of acceptability and feasibility, but not appropriateness. Analyses with the implementation climate subscales showed stronger associations for therapists' perceptions of the treatment methods than of screening tools. CONCLUSIONS: Leaders may promote positive implementation outcomes, both directly and through implementation climate. With regard to the effect sizes and explained variance, results indicated that both implementation leadership and implementation climate were more strongly associated with the therapists' perceptions of the treatment methods, implemented by one group of therapists, than the screening tools, implemented by all therapists. This may imply that implementation leadership and climate may have stronger effects for smaller implementation teams within a larger system than for system-wide implementations or when the clinical interventions being implemented are more complex rather than simple ones. TRIAL REGISTRATION: ClinicalTrials NCT03719651, 25 October 2018.

Evaluating Links between Social Withdrawal Motivations and Indices of Psychosocial Adjustment among Norwegian Emerging Adults.

Social withdrawal is the behavioral tendency to remove oneself from social situations - a tendency that often contributes to reductions in individuals' mental health. The current study evaluated the links between different motivations for social withdrawal (shyness, unsociability, social avoidance) and indices of psychosocial adjustment in a Norwegian sample of emerging adults. Participants were N = 194 Norwegian university students who completed self-report measures of life satisfaction, loneliness, and depressive symptoms, as well as withdrawal motivations. Among the results, a newly translated version of the Social Preference Scale-Revised (SPS-R) was validated for use in Norway. Findings showed that shyness was uniquely and positively associated with loneliness and depressive symptoms, as well as lower life satisfaction, whereas social avoidance was positively associated with depressive symptoms. Unsociability was uniquely linked to lower levels of loneliness and depressive symptoms. Findings provide novel information about the psychosocial correlates of social withdrawal motivations during emerging adulthood in the under-explored cultural context of Norway. Understanding nuances in the correlates of different motivations may aid in the development of culturally and developmentally sensitive interventions.

Validation of the Norwegian versions of the Implementation Leadership Scale (ILS) and Multifactor Leadership Questionnaire (MLQ) in a mental health care setting.

BACKGROUND: The implementation of evidence-based practices (EBPs) is of crucial importance in health care institutions and requires effective management from leaders. However, there is a lack of assessment tools sufficient to evaluate the degree to which the employees´ rate how well their leaders are at implementing EBPs. This emphasises the need for validated and widely used scales relevant for EBPs. METHODS: The current study evaluated the psychometric properties of the Multifactor Leadership Questionnaire (MLQ) and Implementation Leadership Scale (ILS) in a Norwegian mental health care setting. RESULTS: Results from confirmatory factor analyses indicate that the MLQ and ILS are valid instruments for measuring general and implementation leadership. The scales demonstrate good convergent validity. In addition, attitudes towards EBPs did not seem to be associated with the ILS and MLQ, further supporting the applicability of the instruments. CONCLUSIONS: The two scales demonstrate good psychometric properties in a Norwegian mental health care setting, which suggests that the MLQ and ILS are valid and reliable tools for measuring leadership in an implementation setting. More research is greatly needed to disentangle the link between perceived leadership and objective measures of successful implementation of EBPs. Trial registration NSD 690,133, NSD 60,059/3/OOS.

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study.

Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

Antecedentes: El trastorno de estrés postraumático complejo (TEPT-C) ha sido agregado recientemente al sistema de diagnóstico para la clasificación de enfermedades CIE-11. El nuevo trastorno agrega tres grupos de síntomas al trastorno de estrés postraumático (TEPT), relacionados con alteraciones en la autoorganización (desregulación afectiva, autoconcepto negativo y alteraciones en las relaciones). Poco se sabe acerca de si los tratamientos basados en evidencia recomendados para el TEPT en jóvenes son útiles para los jóvenes con TEPT-C.Objetivos: Este estudio examinó si la Terapia Cognitiva Conductual Centrada en el Trauma (TF-CBT en sus siglas en inglés) es útil para reducir el TEPT y el TEPT-C en jóvenes traumatizados.Método: Se incluyó en el estudio a jóvenes derivados a una de las 23 clínicas noruegas de salud mental para niños y adolescentes, que cumplían con los criterios para TEPT o TEPT-C según el CIE-11 y recibieron TF-CBT (n = 73, 89% niñas, M edad = 15,4, DE = 1,8). Se realizaron evaluaciones antes del tratamiento y cada cinco sesiones. Se ejecutaron modelos de efectos mixtos lineales para investigar si los jóvenes con TEPT-C y TEPT respondían de manera diferente a la TF-CBT.Resultados: Entre los 73 jóvenes, el 61,6% (n = 45) cumplió con los criterios de TEPT-C y el 38,4% (n = 28) cumplió con los criterios de TEPT. No hubo diferencias en sexo, edad, país de nacimiento, tipo de trauma, número de tipos de trauma o duración del tratamiento entre los grupos. Los jóvenes con TEPT-C tuvieron una disminución más pronunciada en TEPT y TEPT-C en comparación con los jóvenes con TEPT. Los grupos reportaron niveles similares de TEPT y TEPT-C después del tratamiento. El porcentaje de jóvenes que abandonaron el tratamiento no difirió entre los grupos. Además, los grupos no difirieron significativamente en el número de sesiones de tratamiento recibidas.Conclusiones: Éste es el primer estudio que examina si la TF-CBT es útil para los jóvenes que tienen TEPT-C mediante un instrumento validado para medir el TEPT. Los resultados sugieren que la TF-CBT puede ser útil para tratar el TEPT-C en jóvenes. Estos son hallazgos prometedores que deberían replicarse en estudios con tamaños muestrales más grandes.