Ecological momentary assessment of heavy episodic drinking in the early postpartum period: A feasibility study.

Background: Postpartum mothers are at heightened risk for heavy episodic drinking (HED). Research with this population is critical to developing acceptable and effective tailored interventions, but new mothers who use alcohol are often reluctant to engage in research due to stigma and fear of child removal. This study examined feasibility of recruitment and ecological momentary assessment (EMA) in early postpartum mothers with histories of HED. Methods: Participants were recruited via Facebook and Reddit and completed 14 days of EMA surveys. Baseline characteristics, recruitment feasibility, and EMA feasibility and acceptability were examined. Participants attended focus groups to further inform quantitative data. Results: Reddit yielded a larger proportion of eligible individuals than Facebook, and 86% of the final enroled sample was recruited via Reddit. The average compliance rate of 75% is in line with other studies of similar populations. Half the sample reported alcohol use, and 78% reported the urge to drink at least once, supporting feasibility of EMA for collecting alcohol use data. Participants reported low burden and high acceptability of the study on both quantitative and qualitative measures. Baseline low maternal self-efficacy was associated with greater EMA compliance, and first-time mothers reported lower EMA burden compared to veteran mothers. College graduates, and participants with lower drinking refusal self-efficacy and greater alcohol severity were more likely to report alcohol use on EMA. Conclusions: Future studies should consider Reddit as a recruitment strategy. Findings generally support feasibility and acceptability of EMA to assess HED in postpartum mothers.

Core Elements of Family Therapy for Adolescent Behavioral Health Problems: Validity Generalization in Community Settings.

OBJECTIVE: The core elements of family therapy for adolescent mental health and substance use problems, originally distilled from high-fidelity sessions conducted by expert clinicians, were tested for validity generalization when delivered by community therapists in routine settings. METHOD: The study sampled recorded sessions from 161 cases participating in one of three treatment pools: implementation trial of Functional Family Therapy (98 sessions/50 cases/22 therapists), adaptation trial of Multisystemic Therapy (115 sessions/59 cases/2 therapists), and naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases/21 therapists). Adolescents were identified as 60% male and 40% female with an average age of 15.4 years; 49% were Latinx, 27% White Non-Latinx, 15% African American, 3% another race/ethnicity, 6% race/ethnicity unknown. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete family therapy techniques. Archived data of one-year clinical outcomes were gathered. RESULTS: Confirmatory factor analyses replicated the factor structure from the original distillation study, retaining all four clinically coherent treatment modules comprised of all 21 techniques: Interactional Change (ICC = .77, Cronbach's α = .81); Relational Reframe (ICC = .75, α = .81); Adolescent Engagement (ICC = .72, α = .78); Relational Emphasis (ICC = .76, α = .80). Exploratory analyses found that greater use of core techniques predicted symptom improvements in one treatment pool. CONCLUSIONS: Core techniques of family therapy distilled from manualized treatments for adolescent behavioral health problems showed strong evidence of validity generalization, and initial evidence of links to client outcomes, in community settings.

Development of an Electronic Screening and Brief Intervention to Address Perinatal Substance Use in Home Visiting: Qualitative User-Centered Approach.

BACKGROUND: Perinatal substance use (SU) is prevalent during pregnancy and the postpartum period and may increase the risks to maternal and child health. Many pregnant and postpartum women do not seek treatment for SU because of fear of child removal. Home visiting (HV), a voluntary supportive program for high-risk families during the perinatal period, is a promising avenue for addressing unmet SU needs. Confidential delivery of screening and brief intervention (BI) for SU via computers has demonstrated high user satisfaction among pregnant and postpartum women as well as efficacy in reducing perinatal SU. This study describes the development of the electronic screening and BI for HV (e-SBI-HV), a digital screening and BI program that is adapted from an existing electronic screening and BI (e-SBI) for perinatal SU and tailored to the HV context. OBJECTIVE: This study aimed to describe the user-centered intervention development process that informed the adaptation of the original e-SBI into the e-SBI-HV, present specific themes extracted from the user-centered design process that directly informed the e-SBI-HV prototype and describe the e-SBI-HV prototype. METHODS: Adaptation of the original e-SBI into the e-SBI-HV followed a user-centered design process that included 2 phases of interviews with home visitors and clients. The first phase focused on adaptation and the second phase focused on refinement. Themes were extracted from the interviews using inductive coding methods and systematically used to inform e-SBI-HV adaptations. Participants included 17 home visitors and 7 clients across 3 Healthy Families America programs in New Jersey. RESULTS: The e-SBI-HV is based on an existing e-SBI for perinatal SU that includes screening participants for SU followed by a brief motivational intervention. On the basis of the themes extracted from the user-centered design process, the original e-SBI was adapted to address population-specific motivating factors, address co-occurring problems, address concerns about confidentiality, acknowledge fear of child protective services, capitalize on the home visitor-client relationship, and provide information about SU treatment while acknowledging that many clients prefer not to access the formal treatment system. The full e-SBI-HV prototype included 2 digital intervention sessions and home visitor facilitation protocols. CONCLUSIONS: This study describes a user-centered approach for adapting an existing e-SBI for SU for use in the HV context. Despite the described challenges, home visitors and clients generally reacted favorably to the e-SBI-HV, noting that it has the potential to fill a significant gap in HV services. If proven effective, the e-SBI-HV could provide a way for clients to receive help with SU within HV, while maintaining their privacy and avoiding the overburdening of home visitors. The next step in this study would be to test the feasibility and preliminary efficacy of the e-SBI-HV.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study.

BACKGROUND: Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non-treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking. OBJECTIVE: The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI. METHODS: This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described. RESULTS: Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022. CONCLUSIONS: The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36849.

Postpartum heavy episodic drinking: A survey to inform development of a text messaging intervention.

INTRODUCTION: Text messaging interventions (TMI) are promising for addressing heavy episodic drinking (HED) in non-treatment-seeking postpartum women. Their anonymous delivery can overcome fear of consequences that often prevents postpartum women from seeking treatment for HED. We assessed feasibility and acceptability of text messaging to inform the development of a tailored TMI for postpartum HED. METHODS: We surveyed 165 postpartum women recruited via a national Qualtrics panel on their drinking behaviours, mobile technology use and TMI preferences. RESULTS: Twenty-five percent of the sample (N = 41) were classified as heavy episodic drinkers, with significant drinking reported before, during and after pregnancy, supporting the need for intervention. Feasibility of text messaging was supported by nearly universal mobile phone ownership and text messaging. Attitudes and intervention preferences varied, with 30% of HEDs likely to participate in an intervention asking them to receive automated messages, and 46% likely to participate in an intervention that included live texting with a counsellor. Respondents were more likely to participate in a study that asked them to respond to messages about mood and stress (63%) than daily drinking behaviours (35%), and were most interested in a TMI that included live texting with a counsellor. Nearly half the sample endorsed fear of child removal as a significant barrier to participation. DISCUSSION AND CONCLUSIONS: Findings support the feasibility of text messaging as an intervention approach for postpartum HEDs. Postpartum women may have unique concerns and preferences that differ from other groups of HEDs, making a user-centred design approach critical.

Gaps in Screening Recommendations Must Be Addressed to Protect Youth and Adults from Substance Use-Related Harm.

Background: In June 2020, the U.S. Preventive Services Task Force (USPSTF) issued a final recommendation on screening for unhealthy drug use in adults and adolescents. It assigned a "B" rating on a recommendation for screening in primary care for adults when services for accurate diagnosis, effective treatment, and appropriate care can be provided or referred, but declined to recommend the same for adolescents, concluding that current evidence is insufficient to assess the balance of benefits and harms. Objectives: To examine and provide recommendations to address gaps in the USP ST recommendation on screening for unhealthy drug use. Results: The lack of recommendation to screen adolescents represents a critical gap and highlights the need for research on adolescent substance use screening. While research is limited, available evidence shows short-term benefits from youth screening and early intervention and no evidence of harm. The lack of recommendation for youth leaves practitioners without guidance and incentive to intervene with youth who use substances, discourages expansion/support of youth screening, and reinforces treatment barriers. The statement also lacks guidance to address barriers to implementing screening in adults. Despite promotion of the practice, implementation in primary care is sporadic. Providers should be made aware of implementation barriers and the clinical guides and training available to facilitate implementation. Conclusions/Importance: Screening and intervention are vital for addressing the addiction crisis, and USPSTF recommendations are critical for making preventive health care services accessible and affordable. These gaps must be addressed for the recommendation statement to reach its full life-saving potential.

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

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

Conceptual framework for telehealth strategies to increase family involvement in treatment and recovery for youth opioid use disorder.

With opioid use at crisis levels, it is imperative to support youth ages with opioid use disorders (OUD) in taking medication and accessing behavioral services over long periods. This article presents a conceptual framework for telehealth strategies that can be adopted to increase family involvement across a four-stage continuum of youth OUD treatment and recovery: Treatment Preparation, Treatment Initiation, Treatment Stabilization, OUD Recovery. It first identifies provider-delivered tele-interventions that can enhance OUD services in each of the four stages, including family outreach, family engagement, family-focused intervention, and family-focused recovery maintenance. It then introduces several types of direct-to-family tele-supports that can be used to supplement provider-delivered interventions. These include both synchronous tele-supports (remote interactions that occur in real time) such as helplines, peer-to-peer coaching, and online support groups; and asynchronous tele-supports (communications that occur without participants being simultaneously present) such as automated text messaging, self-directed internet-based courses, and digital web support.

DIfferences in Treatment Trajectories Between Two Profiles of Adolescent Systems Involvement.

Of adolescents utilizing behavioral health services, between 45% and 62% (Farmer et al., 2003; Merikangas et al., 2011) become involved in multiple systems (i.e., mental health, juvenile justice, child welfare, and education systems) to meet their behavioral health needs (e.g., Glisson & Green, 2006). Despite their involvement in treatment, these youths often still have unmet needs due to lack of integrated care across systems (e.g., Hawkins, 2009). Adolescent behavior problems may be conceptualized differently to account for the unique needs of youth involved in multiple systems. Using a sample of 433 youth in need of behavioral health treatment services, we: (1) identified distinct classes of systems involvement across four systems, (2) compared youth comprising these classes on demographics and DSM-IV diagnoses, and (3) examined changes in delinquency and substance use over time among the youth comprising the systems involvement class groupings. Using latent class analysis, we identified two distinct classes of adolescent systems involvement: one with heavy involvement in all systems and the other with high involvement in only the education and mental health systems. Latent growth curve analyses using most likely class membership as a predictor demonstrated that adolescents with heavy involvement in all systems showed significantly more decreases in delinquent activity than comparison youth, but less decreases in substance use over a one-year follow-up period. Our findings support that it is clinically useful to examine classes of multiple systems involvement. Treatment providers can use these findings identify whether or not their clients are heavily involved in all systems and tailor their approach accordingly. In addition, researchers can continue to parse out differences in treatment trajectories for multiple systems involved youth as well as the various factors impacting these differences.

Randomized Trial of Academic Training and Medication Decision-Making for Adolescents with ADHD in Usual Care.

Objective: This study tested two family-based interventions designed for delivery in usual care: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA), containing motivational interventions, homework management and schoolwork organization training, and family-school partnership building; and Medication Integration Protocol (MIP), containing ADHD psychoeducation, medication decision-making, and integrated medication management.Method: This study used a cluster randomized design to test CASH-AA + MIP versus CASH-AA Only for adolescents with ADHD in five sites. Therapists (N = 49) were site clinicians randomized to condition. Clients (N = 145) included 72% males; 42% White Non-Hispanic, 37% Hispanic American, 15% African American, and 6% more than one race; average age was 14.8 years. Fidelity data confirmed protocol adherence and between-condition differentiation.Results: One-year improvements were observed across conditions in several outcomes. Overall, CASH-AA + MIP produced greater declines in adolescent-report inattentive symptoms and delinquent acts. Similarly, among non-substance users, CASH-AA + MIP clients attended more treatment sessions. In contrast, among substance users, CASH-AA Only clients showed greater declines in caregiver-report hyperactive symptoms and externalizing.Conclusions: This study provides initial experimental support for family-based ADHD medication decision-making when coupled with academic training in usual care. The treatment protocols, CASH-AA and MIP, showed positive effects in addressing not only ADHD symptoms but also common co-occurring problems, and youth with substance use problems benefitted along with non-using peers.

Systematic Review of Community- and Home-Based Interventions to Support Parenting and Reduce Risk of Child Maltreatment Among Families With Substance-Exposed Newborns.

Substance-exposed newborns (SENs) are at increased risk of child maltreatment, out-of-home placement, and poor health and developmental outcomes. The purpose of this systematic review is to synthesize existing research on community- and home-based interventions designed to improve parenting and reduce risk of maltreatment for families with SENs, applying a program logic framework. The review includes studies that used preexperimental, quasi-experimental, and experimental designs. Twelve interventions were identified. Of the nine studies that used more rigorous experimental or quasi-experimental designs, five showed positive effects on at least one parenting or child maltreatment outcome, although some studies showed high risk of bias. Full coherence among the intended participants, theory of change, and program components was observed for only two interventions. The findings suggest a need for more rigorous research to develop and test interventions that are grounded in theory and prior research and that address the unique needs of families with SENs.

Addressing Maternal Depression, Substance Use, and Intimate Partner Violence in Home Visiting: a Quasi-Experimental Pilot Test of a Screen-and-Refer Approach.

This quasi-experimental pilot study describes preliminary impacts of the "Home Visitation Enhancing Linkages Project (HELP)," a pragmatic screen-and-refer approach for promoting identification of and linkage to treatment for maternal depression (MD), substance use (SU), and intimate partner violence (IPV) within early childhood home visiting. HELP includes screening for MD, SU, and IPV followed by a menu of motivational interviewing and case management interventions aimed at linking clients to treatment, designed for delivery within routine home visiting. HELP was piloted within four counties of a statewide home visiting system that were implementing Healthy Families America. HELP clients (N = 394) were compared to clients in five demographically matched counties that received usual Healthy Families services (N = 771) on whether their home visitors (1) identified MD, SU, and IPV risk; (2) discussed MD, SU, and IPV during home visits; and (3) made referrals for MD, SU, and IPV. All data were extracted from the program's management information system. A significant impact of HELP was found on discussion of risk in home visits for all three risk domains with large effect sizes (MD OR = 4.08; SU OR = 15.94; IPV OR = 9.35). HELP had no impact on risk identification and minimal impact on referral. Findings provide preliminary support for HELP as a way of improving discussion of client behavioral health risks during home visits, an important first step toward better meeting these needs within home visiting. However, more intensive intervention is likely needed to impact risk identification and referral outcomes.

Measurement Training and Feedback System for Implementation of family-based services for adolescent substance use: protocol for a cluster randomized trial of two implementation strategies.

BACKGROUND: This article describes a study protocol for testing the Measurement Training and Feedback System for Implementation (MTFS-I) and comparing two implementation strategies for MTFS-I delivery. MTFS-I is a web-based treatment quality improvement system designed to increase the delivery of evidence-based interventions for behavioral health problems in routine care settings. This version of MTFS-I focuses on family-based services (FBS) for adolescent substance use. FBS, comprising both family participation in treatment and family therapy technique use, have achieved the strongest evidence base for adolescent substance use and are a prime candidate for upgrading treatment quality in outpatient care. For FBS to fulfill their potential for widespread dissemination, FBS implementation must be bolstered by effective quality procedures that support sustainable delivery in usual care. METHODS/DESIGN: Adapted from measurement feedback systems for client outcomes, MTFS-I contains three synergistic components: (a) weekly reporter training modules to instruct therapists in reliable post-session self-reporting on FBS utilization; (b) weekly mock session videos of FBS interventions (5-8 min) for supportive training in, and practice coding of, high-quality FBS; and (c) monthly feedback reports to therapists and supervisors displaying aggregated data on therapist-reported FBS use. MTFS-I is hosted online and requires approximately 20 min per week to complete. The study will experimentally compare two well-established implementation strategies designed to foster ongoing MTFS-I usage: Core Training, consisting of two 3-h training sessions focused on FBS site mapping, selecting FBS improvement goals, and sustaining MTFS-I, followed by routine remote technical assistance; and Core + Facilitation, which boosts Core Training sessions with collaborative phone-based clinical consultation and on-site facilitation meetings for 1 year to promote FBS goal achievement. The study design is a cluster randomized trial testing Core Training versus Core + Facilitation in ten substance use treatment clinics. Study aims will compare conditions on MTFS-I uptake, FBS delivery (based on therapist-report and observational data), and 1-year client outcomes. DISCUSSION: Study contributions to implementation science and considerations of MTFS-I sustainability are discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT03342872 . Registered 10 November 2017.

Core Elements of Family Therapy for Adolescent Behavior Problems: Empirical Distillation of Three Manualized Treatments.

Family therapy has the strongest evidence base for treating adolescent conduct and substance use problems, yet there remain substantial barriers to widespread delivery of this approach in community settings. This study aimed to promote the feasibility of implementing family-based interventions in usual care by empirically distilling the core practice elements of three manualized treatments. The study sampled 302 high-fidelity treatment sessions from 196 cases enrolled in 1 of 3 manualized family therapy models: multidimensional family therapy (102 sessions/56 cases), brief strategic family therapy (100 sessions/94 cases), or functional family therapy (100 sessions/46 cases). Adolescents were 57% male; 41% were African American, 31% White non-Hispanic, 9% Hispanic American, 6% another race/ethnicity, and 13% unknown. The observational fidelity measures of all three models were used to code all 302 sessions. Fidelity ratings were analyzed to derive model-shared treatment techniques via exploratory factor analyses on half the sample; the derived factors were then validated via confirmatory factor analyses supplemented by Bayesian structural equation modeling on the remaining half. Factor analyses distilled 4 clinically coherent practice elements with strong internal consistency: Interactional Change (6 treatment techniques; Cronbach's α = .93), Relational Reframe (7 techniques; α = .79), Adolescent Engagement (4 techniques; α = .68), and Relational Emphasis (4 techniques; α = .67). The 4 empirically derived factors represent the core elements of 3 manualized family therapy models for adolescent behavior problems, setting the foundation of a more sustainable option for delivering evidence-based family interventions in routine practice settings. Public Health Significance: Increasing implementation of high-fidelity family-based interventions would improve the quality of treatment services for adolescent conduct and substance use problems.

Family therapy techniques and one-year clinical outcomes among adolescents in usual care for behavior problems.

OBJECTIVE: This study tested whether use of family therapy (FT) techniques predicted long-term clinical outcomes in usual care for adolescents enrolled in either family-based or non-family-based treatment for conduct and substance use problems. METHOD: Participants included 70 adolescents (53% female; mean age 15.4 years) from diverse backgrounds (64% Hispanic, 16% African American, 11% multiracial) assessed at baseline and 3-, 6-, and 12-month follow-up. Utilization of FT techniques was assessed for 802 therapy sessions via a therapist-report tool that collected postsession data on delivery of core treatment techniques of the FT approach. RESULTS: Latent growth curve modeling was used to examine individual change over 12-month follow-up. FT technique scores, averaged across treatment sessions, were included as a predictor in latent growth models, controlling for adolescent age, sex, and ethnicity. More extensive use of core FT techniques predicted significant decreases in adolescent-reported delinquency and externalizing behavior and marginal decreases in substance use and parent-reported externalizing for cases in both family and nonfamily treatment. CONCLUSIONS: Greater use of FT techniques in routine care was associated with better long-term adolescent outcomes, regardless of whether clients attended services featuring family therapy or an alternative treatment approach. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Perceived Need for Treatment and Engagement in Mental Health Services Among Community-Referred Racial/Ethnic Minority Adolescents.

This study examines clinical and family predictors of perceived need for treatment and engagement in mental health treatment services among community-referred racial/ethnic minority adolescents and their primary caregivers. Findings indicated that the majority of families perceived a need for treatment, but that perceived need was not associated with treatment engagement. Family factors (i.e., low cohesion and high conflict within the family) predicted perceived need for treatment among adolescents, whereas clinical factors (i.e., adolescent internalizing and externalizing symptomatology) predicted caregiver perceived need for adolescent treatment. Neither clinical nor family factors predicted treatment engagement.

Development and implementation of a screen-and-refer approach to addressing maternal depression, substance use, and intimate partner violence in home visiting clients.

Perinatal maternal depression (MD), substance use (SU), and intimate partner violence (IPV) are critical public health concerns with significant negative impacts on child development. Bolstering the capacity of home visiting (HV) programs to address these significant risk factors has potential to improve child and family outcomes. This study presents a description and mixed-methods feasibility evaluation of the "Home Visitation Enhancing Linkages Project (HELP)," a screen-and-refer approach to addressing MD, SU, and IPV within HV aimed at improving risk identification and linkage to treatment among HV clients. HELP was a three-phase intervention that included three evidence-based interventions: screening, motivational interviewing (MI), and case management (CM). This study presents quantitative fidelity data from 21 home visitors reporting on 116 clients in 4 HV programs, as well as qualitative data from structured interviews with 14 home visitors. Nearly all clients were screened and 22% screened positive on at least one risk domain. Rates of MI and CM implementation were lower than expected, however home visitors implemented general supportive interventions at high rates. Home visitor interviews revealed the following factors that may have impacted HELP implementation: client disclosure of risk, barriers to treatment access, systems integration, home visitor role perception, and integration of HELP into the broader HV curriculum. Implications of study findings for the design of future attempts to address maternal risk within HV are discussed.

Substance Use and Depression in Home Visiting Clients: Home Visitor Perspectives on Addressing Clients' Needs.

Substance use and depression are prevalent among mothers enrolled in home visiting programs and are significant risk factors for child maltreatment, yet most home visiting programs are staffed by workers who lack the training and clinical skills to address these risks. Emanating from one state network's interest in advancing its practice in this area, the current study surveyed 159 home visitors on their current practices, training, knowledge, and perceived self­efficacy, and perceived system­ and client­level barriers regarding client substance use and depression. Home visitors reported managing maternal depression more extensively than substance use, though overall management of both risk areas was low. More training was associated with more extensive management of both risk domains, as was greater home visitor knowledge and self­efficacy. Implications for the development of strategies to improve home visitor management of client behavioral health risks, including enhanced skills­based training and supervision, are discussed.

Distilling the Core Elements of Family Therapy for Adolescent Substance Use: Conceptual and Empirical Solutions.

This article describes several barriers to widespread dissemination of manualized family-based treatments for adolescent substance use (ASU). We then offer a highly promising solution for adopting and sustaining family therapy in usual care: distilling the core practice elements of empirically validated family therapy models for ASU. We present a conceptual distillation of family therapy for ASU grounded in existing observational fidelity measures for three manualized models, a process that yielded four core elements: Family Engagement, Relational Reframing, Family Behavior Change, and Family Restructuring. We then introduce an innovative empirical method for distilling core elements that can serve as a template for rigorous distillation of other treatment approaches. Finally, we discuss how core elements can enhance family therapy services within the diverse workforce of usual care for ASU.

Benchmarking Family Therapy for Adolescent Behavior Problems in Usual Care: Fidelity, Outcomes, and Therapist Performance Differences.

This study evaluated whether community therapists delivering family therapy for adolescent behavior problems in usual care achieved performance benchmarks established in controlled trials for treatment fidelity and outcomes, with particular focus on individual differences in therapist performance. The study contained N = 38 adolescents (50 % male; mean age 15 years) whose self-reported race/ethnicity was Hispanic (74 %), African American (11 %), multiracial (11 %), and other (4 %). Clients were treated by 13 therapists in one community mental health clinic that delivered family therapy as the routine standard of care. Therapists provided self-report data on adherence to core family therapy techniques; these scores were inflation-adjusted based on concordance with observer reports. Results showed that community therapists surpassed the fidelity benchmark for core family therapy techniques established by research therapists during a controlled trial. Regarding change in client functioning at 6-month follow-up, community therapists were equivalent to the benchmark for internalizing symptoms and superior for externalizing symptoms and delinquent acts. Community therapists also demonstrated a high degree of performance uniformity: Each one approximated the fidelity benchmark, and only two produced relatively weak outcomes on any of the client change indicators. Caveats for interpreting therapist performance data, given the small sample size, are described. Recommendations are made for developing therapist-report fidelity measures and utilizing statistical process control methods to diagnose therapist differences and enhance quality assurance procedures.