Youth Top Problems in an Acute Psychiatric Sample: Describing Consumer-Nominated Treatment Needs in an Adolescent Partial Hospital Setting.

Given the wide range of diagnostic presentations treated in partial hospital programs, finding efficient ways to identify and measure progress on the chief concerns of consumers in these settings is important. The current study uses a self-administered version of the Top Problems Assessment to describe treatment targets identified by youth and their caregivers presenting for care at an adolescent partial hospital setting. Caregiver-youth agreement on these chief concerns upon admission and predictors of agreement were explored. About one-third (34.65%) of caregiver-youth pairs did not match on any target problems. Although anxiety and depression were the most commonly cited top problems in this sample, caregivers and youth exhibited disagreement on these domains. Treatment teams in acute care settings such as a partial hospital program can benefit from careful assessment surrounding the initial goals of treatment as youth and their caregivers may not agree on the referral problems upon entering a program.

Assessing practical implementation of modular psychotherapy for youth in community-based settings using benchmarking.

Background: Achieving high quality outcomes in a community context requires the strategic coordination of many activities in a service system, involving families, clinicians, supervisors, and administrators. In modern implementation trials, the therapy itself is guided by a treatment manual; however, structured supports for other parts of the service system may remain less well-articulated (e.g., supervision, administrative policies for planning and review, information/feedback flow, resource availability). This implementation trial investigated how a psychosocial intervention performed when those non-therapy supports were not structured by a research team, but were instead provided as part of a scalable industrial implementation, testing whether outcomes achieved would meet benchmarks from published research trials. Method: In this single-arm observational benchmarking study, a total of 59 community clinicians were trained in the Modular Approach to Therapy for Children (MATCH) treatment program. These clinicians delivered MATCH treatment to 166 youth ages 6 to 17 naturally presenting for psychotherapy services. Clinicians received substantially fewer supports from the treatment developers or research team than in the original MATCH trials and instead relied on explicit process management tools to facilitate implementation. Prior RCTs of MATCH were used to benchmark the results of the current initiative. Client improvement was assessed using the Top Problems Assessment and Brief Problem Monitor. Results: Analysis of client symptom change indicated that youth experienced improvement equal to or better than the experimental condition in published research trials. Similarly, caregiver-reported outcomes were generally comparable to those in published trials. Conclusions: Although results must be interpreted cautiously, they support the feasibility of using process management tools to facilitate the successful implementation of MATCH outside the context of a formal research or funded implementation trial. Further, these results illustrate the value of benchmarking as a method to evaluation industrial implementation efforts.Plain Language Summary: Randomized effectiveness trials are inclusive of clinicians and cases that are routinely encountered in community-based settings, while continuing to rely on the research team for both clinical and administrative guidance. As a result, the field still struggles to understand what might be needed to support sustainable implementation and how interventions will perform when brought to scale in community settings without those clinical trial supports. Alternative approaches are needed to delineate and provide the clinical and operational support needed for implementation and to efficiently evaluate how evidence-based treatments perform. Benchmarking findings in the community against findings of more rigorous clinical trials is one such approach. This paper offers two main contributions to the literature. First, it provides an example of how benchmarking is used to evaluate how the Modular Approach to Therapy for Children (MATCH) treatment program performed outside the context of a research trial. Second, this study demonstrates that MATCH produced comparable symptom improvements to those seen in the original research trials and describes the implementation strategies associated with this success. In particular, although clinicians in this study had less rigorous expert clinical supervision as compared with the original trials, clinicians were provided with process management tools to support implementation. This study highlights the importance of evaluating the performance of intervention programs when brought to scale in community-based settings. This study also provides support for the use of process management tools to assist providers in effective implementation.

Child STEPs in California: A cluster randomized effectiveness trial comparing modular treatment with community implemented treatment for youth with anxiety, depression, conduct problems, or traumatic stress.

OBJECTIVE: This study reports outcomes from a randomized effectiveness trial testing modular treatment versus multiple community-implemented evidence-based treatments for youth. METHOD: An ethnoracially diverse sample of 138 youth ages 5 to 15 (62 girls, 76 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, disruptive behavior, and/or traumatic stress were treated by community therapists randomly assigned to 1 of 2 conditions: (a) modular treatment, which involved a single modular protocol (i.e., modular approach to therapy for children; MATCH) that allowed flexible selection and sequencing of procedures to fit the chosen treatment focus in the context of measurement feedback, and (b) community-implemented treatment (CIT), which was a county-supported implementation of multiple evidence-based practices for youth. RESULTS: Youth treated with MATCH showed significantly faster rates of improvement over time on clinical and functional outcomes relative to youth in the CIT condition and required significantly fewer sessions delivered over significantly fewer days. Caregiver-reported clinical improvement rates were significantly greater for MATCH (60%) versus CIT (36.7%). Further, youth in the CIT condition were significantly more likely to receive additional psychosocial treatment services and were significantly more likely to use a variety of psychotropic medications during the active treatment phase. CONCLUSIONS: These results extend prior findings, supporting the effectiveness and efficiency of a modular, multifocus approach that incorporates monitoring and feedback relative to community implementation of evidence-based treatments. (PsycINFO Database Record

A longitudinal multilevel model analysis of the within-person and between-person effect of effortful engagement and academic self-efficacy on academic performance.

Using data from an accelerated longitudinal study, we examined the within-person and between-person effect of effortful engagement and academic self-efficacy on academic performance across students (N=135) in elementary school. Teachers assessed participants' effortful engagement and participants rated their academic self-efficacy once per year for 3 years. Academic performance was assessed through standardized test scores in reading and math. Multilevel models indicated that within-person change in Effortful Engagement and Academic Self-Efficacy scores significantly predicted concomitant within-person change in reading test scores, B=2.71, p=.043, Pseudo-R2=.02 and B=4.72, p=.005, Pseudo-R2=.04, respectively. Participants with higher between-person levels of Effortful Engagement had higher initial reading test scores, B=10.03, p=.001, Pseudo-R2=.09, and math test scores, B=11.20, p<.001, Pseudo-R2=.15, whereas participants with higher between-person levels of Academic Self-Efficacy showed a faster rate of increase in math test scores across elementary school, B=10.21, p=.036, Pseudo-R2=.25. At the between-person level, Effortful Engagement mediated the association between Academic Self-Efficacy and both reading and math test scores, although no support was found for mediation at the within-person level. Collectively, results suggest that trait-level psychological factors can vary meaningfully within school-aged children and that both within-person change and between-person individual differences in these traits have important consequences for academic performance.

The relationship between alliance and client involvement in CBT for child anxiety disorders.

Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. The sample was 31 child participants (M age = 9.58 years, SD = 2.17, range = 6-13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (Session 2) and late (Session 8) treatment phases. Two independent coding teams rated alliance and client involvement. Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.

Effectiveness of modular CBT for child anxiety in elementary schools.

Most randomized controlled trials of cognitive-behavioral therapy (CBT) for children with anxiety disorders have evaluated treatment efficacy using recruited samples treated in research settings. Clinical trials in school settings are needed to determine if CBT can be effective when delivered in real world settings. This study evaluated a modular CBT program for childhood anxiety disorders in two elementary schools. Forty children (5-12 years old) with anxiety disorders, referred by teachers and school staff, were randomly assigned to modular CBT or a 3-month waitlist. Clinicians worked with individual families as well as teachers and school staff. Evaluators blind to treatment condition conducted structured diagnostic interviews and caregivers and children completed symptom checklists at pre- and posttreatment. The primary study outcome, the Clinical Global Impressions-Improvement scale, yielded a positive treatment response at posttreatment for 95.0% of CBT participants, as compared with only 16.7% of the waitlist participants. CBT also outperformed the waitlist on diagnostic outcomes and caregiver-report measures of anxiety. Treatment effects did not extend beyond anxiety diagnoses and symptoms. Results suggest that modular CBT delivered within the elementary school setting may be effective for the treatment of child anxiety disorders. A replication of the study results with a larger sample is indicated.

One year follow-up to modular cognitive behavioral therapy for the treatment of pediatric anxiety disorders in an elementary school setting.

The current study sought to evaluate the relative long-term efficacy of a modularized cognitive behavioral therapy (CBT) program for children with anxiety disorders. Twenty four children (5-12 years old) randomly assigned to modular CBT or a 3-month waitlist participated in a 1-year follow-up assessment. Independent evaluators blind to treatment condition conducted structured diagnostic interviews, and caregivers and children completed symptom checklists at pre- and post-, and 1 year follow-up assessments. Analyses revealed that 71.4% of children who received CBT demonstrated a positive treatment response 1 year following treatment, and 83.3% were free of any anxiety diagnosis at 1 year follow-up. Analyses further revealed robust effects of intervention on diagnostic outcomes, caregiver- and child-report measures of anxiety at 1 year follow-up. Results provide evidence of an ongoing advantage on anxiety-specific outcomes for this modularized school-based CBT program 1 year post-treatment.

Child-therapist alliance and clinical outcomes in cognitive behavioral therapy for child anxiety disorders.

BACKGROUND: Few studies have examined the link between child-therapist alliance and outcome in manual-guided cognitive behavioral therapy (CBT) for children diagnosed with anxiety disorders. This study sought to clarify the nature and strength of this relation. METHODS: The Therapy Process Observational Coding System for Child Psychotherapy - Alliance scale (TPOCS-A; McLeod, 2005) was used to assess the quality of the child-therapist alliance. Coders independently rated 123 CBT therapy sessions conducted with 34 children (aged 6-13 years) diagnosed with anxiety disorders. Parents reported on children's symptomatology at pre- mid-, and post-treatment. RESULTS: A stronger child-therapist alliance early in treatment predicted greater improvement in parent-reported outcomes at mid-treatment but not post-treatment. However, improvement in the child-therapist alliance over the course of treatment predicted better post-treatment outcomes. CONCLUSIONS: The quality of the child-therapist alliance assessed early in treatment may be differentially associated with symptom reduction at mid- and post-treatment. Results underscore the importance of assessing the relation between alliance and outcome over the course of therapy to clarify the role the child-therapist alliance plays in child psychotherapy.

Patients' competence in and performance of cognitive therapy skills: relation to the reduction of relapse risk following treatment for depression.

Cognitive therapy (CT) for depression is designed to teach patients material that is believed to help prevent relapse following successful treatment. This study of 35 moderately to severely depressed patients who responded to CT provides the 1st evidence to suggest that both development and independent use of these competencies predict reduced risk for relapse. Among patients who responded to treatment, both CT coping skills and in-session evidence of the independent implementation of CT material predicted lower risk for relapse in the year following treatment. These relationships were not accounted for by either symptom severity at the end of treatment or symptom change from pre- to posttreatment. Self-esteem, assessed at posttreatment, failed to predict risk for relapse in the year following treatment. Thus, CT coping skills and independent use of CT principles, but not overall satisfaction with oneself, appear to play an important role in relapse prevention.