Implementation of the Wolverine Mental Health Program,Part 1: Adoption Phase

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS’s readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.     

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

Adolescent externalizing problems (AEPs), including serious conduct problems, delinquency, and substance misuse, are the most common adolescent behavioral issues in specialty care. High rates of comorbidity between conduct and substance use problems necessitate multidomain treatment strategies that can effectively address the AEP spectrum. One strategy to increase delivery of evidence-based interventions for multiproblem youth in usual care is to focus on core elements of empirically supported treatments that can be judiciously applied to clients presenting with diverse clinical profiles. This paper describes six core practice elements of the cognitive-behavioral treatment (CBT) approach for AEPs: (a) functional analysis of behavior hroblems, (b) prosocial activity sampling, (c) cognitive monitoring and restructuring, (d) emotion regulation training, (e) problem-solving training, and (f) communication training. Integrated delivery of these core CBT elements is illustrated in two case examples, and implications for treatment planning for youth with AEPs are discussed.     

Moving the field of prevention from science to service: Integrating evidence-based preventive interventions into community practice through adapted and adaptive models

The article addresses the adaptation of evidence-based prevention and positive youth development programs for community use. Two complementary approaches for adapting programs are described. In the “adapted” approach, programs are modified to accommodate the culture, climate, and operations of the organization delivering the program. In the “adaptive” approach, programs are modified to accommodate the characteristics, needs and preferences of the individual or family receiving the program. Two examples are provided that illustrate how both adapted and adaptive intervention strategies have been incorporated by community practitioners into the implementation of the Early Risers conduct problems prevention program.     

Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes

Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.     

Parental Involvement: Contribution to Childhood Anxiety and Its Treatment

Anxiety disorders are prevalent in youth. Despite demonstrated efficacy of cognitive behavioral therapy (CBT), approximately 40 % of anxiety-disordered youth remain unresponsive to treatment. Because developmental and etiological models suggest that parental factors are relevant to the onset and maintenance of childhood anxiety, researchers have proposed and investigated family-based interventions with increased parent work in treatment, aiming to improve the efficacy of treatment for childhood anxiety. However, contrary to what theoretical models suggest, data to date did not indicate additive benefit of family-based CBT in comparison with child-centered modality. Is parent/family involvement unnecessary when treating childhood anxiety disorders? Or could there be the need for specificity (tailored family-based treatment) that is guided by a revised conceptualization that improves the implementation of a family-based intervention? The current review examines (1) relevant parental factors that have been found to be associated with the development and maintenance of childhood anxiety and (2) interventions that incorporate parental involvement. Relevant findings are integrated to formulate a “targeted” treatment approach for parental involvement in CBT for youth anxiety. Specifically, there is potential in the assessment of parent/family factors prior to treatment (for appropriateness) followed by a target-oriented implementation of parent training.     

The Unified Protocols for Children and Adolescents in Partial Hospitalization: Using Implementation Science Frameworks to Guide Adaptation

Partial hospitalization programs (PHPs) and other acute mental health treatment programs, which are becoming increasingly common, may help divert children and adolescents from inpatient psychiatric care and provide a concentrated dose of intervention to individuals living in low-resource areas. However, there have been relatively few examinations of the effectiveness of PHPs in addressing emotional concerns (e.g., anxiety, depression, irritability) and functional impairment in youth. Further, evidence-based treatments originally designed for delivery in an outpatient weekly format may require significant adaptation to be appropriate for delivery in acute mental health settings, which differ significantly from weekly outpatient care in program structure, patient acuity, and staffing. In this intervention development and adaptation report, we present the rationale for adapting a transdiagnostic approach to treating emotional disorders—the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A)—for a hospital-based, general psychiatric partial hospitalization program. We use implementation science frameworks to describe our iterative approach to treatment adaptation and testing and to describe in detail proactive, planned adaptations to the UP-C/A for partial hospitalization that occurred prior to initial implementation and pilot testing. Three case examples (child, preadolescent, adolescent) are presented to illustrate how a transdiagnostic approach to care such as the UP-C/A can be used intensively in an acute mental health setting to address emotional and behavioral concerns, including safety.     

Kognitive Verhaltenstherapie bei schizophrenen Psychosen

Cognitive behavioral therapy (CBT) can be regarded as an established intervention for the treatment of patients with schizophrenia. Based on randomized clinical trials and meta-analyses, which found evidence for the efficacy of CBT, almost all evidence-based treatment guidelines recommend CBT for routine treatment. This paper demonstrates that in psychoses CBT is a disorder-specific adaptation of general principles of CBT for the treatment of patients suffering from schizophrenia. The CBT procedure draws on cognitive models of symptoms for the identification of treatment targets and focuses on everyday problems of patients by implementing a self-management approach. Fostering motivation and the application of behavioral and cognitive treatment strategies characterize this approach. If the patients live in a family, other family members should be involved in order to improve crisis management and problem solving within the family. A major challenge for the future is to improve the availability of CBT under the German conditions of routine mental health care.     

Integrating instructional procedures into traditional congregate care situations for people with severe disabilities

Many institutional and community residential agencies experience difficulties in providing habilitative services when direct care staff are working with groups of people with severe disabilities. We evaluated a means of assisting direct care personnel in integrating instructional strategies into traditional congregate care situations. In Experiment 1, integrated teaching strategies were operationalized for two direct care staff persons. The strategies were based on individualized client habilitative goals and the use of brief response prompting and contingent reinforcement paradigms. The staff members integrated the teaching procedures into their group routines with clients upon implementation of an integrated-teaching staff training and management program. The program involved two staff training sessions and ongoing performance feedback. In Experiment 2, four staff members in another living unit integrated the strategies into their group routines upon implementation of a simplified version of the program. Additionally, while the program was in effect, adaptive behaviors increased in frequency for 19 of 20 clients with profound multiple disabilities. Results of the experiments demonstrate a means through which residential agencies may enhance provision of continuous active treatment in accordance with clinical and governmental guidelines. Suggestions for future rescarch are provided, focusing on overcoming obstacles residential personnel face in providing treatment services in congregate situations.     

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12–15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.     

Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients

The purpose of this paper is to outline considerations for adapting cognitive-behavioral therapy (CBT) to Hispanic patients who have recently immigrated, particularly those presenting with depressive symptoms. Culturally competent CBT is framed within a model originally proposed by Rogler and his colleagues (1987). The considerations outlined by the model include ensuring that treatments provide access, are selected based on compatibility with Hispanic culture, and are adapted to fit the culture. Recommendations for culturally adapting CBT include consideration of each patient's unique ethnocultural background and their treatment expectations, as well as culturally relevant interpersonal styles, values, and metaphors/language. In addition, specific strategies for conceptualizing and conducting CBT techniques are discussed.     

Development and Implementation of Health and Wellness CBT for Individuals With Depression and HIV

Rates of depression are reported to be between 22% to 33% in adults with HIV, which is double that of the general population. Depression negatively affects treatment adherence and health outcomes of those with medical illnesses. Further, it has been shown in adults that reducing depression may improve both adherence and health outcomes. To address the issues of depression and nonadherence, Health and Wellness (H&W) cognitive behavioral therapy (CBT) and medication management (MM) treatment strategies have been developed specifically for youth living with both HIV and depression. H&W CBT is based on other studies with uninfected youth and upon research on adults with HIV. H&W CBT uses problem solving, motivational interviewing, and cognitive-behavioral strategies to decrease adherence obstacles and increase wellness. The intervention is delivered in 14 planned sessions over a 6-month period, with three different stages of CBT. This paper summarizes the feasibility and acceptability data from an open depression trial with 8 participants, 16 to 24 years of age, diagnosed with HIV and with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis of depression, conducted at two treatment sites in the Adolescent Trials Network (ATN). Both therapists and subjects completed a Session Evaluation Form (SEF) after each session, and results were strongly favorable. Results from The Quick Inventory of Depressive Symptomatology–Clinician (QIDS-C) also showed noteworthy improvement in depression severity. A clinical case vignette illustrates treatment response. Further research will examine the use of H&W CBT in a larger trial of youth diagnosed with both HIV and depression.     

CBT with Youth: Immodest Proposals for Training the Next Generation

January 2014 brings the inauguration of the Affordable Care Act (ACA) in the United States. The ACA introduces affordable healthcare to all citizens and proposes a system to hold all healthcare providers accountable for quality treatment. This article discusses differences in the new healthcare climate and highlights specific areas of focus for training child clinicians in CBT in the midst of this evolution. Child clinicians, more than ever, will need a sound foundation of CBT theory and training so that they may fluidly practice and apply core principles in any setting, with any intervention. Transformations to the health care arena brought about by the ACA will see doctoral level clinicians practicing in a wider variety of roles, in highly integrated settings, and with an increasingly diverse population. Ability to ground intervention in solid theoretical framework will enable clinicians to practice in these numerous conditions effectively and meet accountability standards set by the ACA. Arming child clinicians with these skills will create a generation of practitioners well-prepared to care for youth in the developing atmosphere of mental health care in the United States.     

Research to Practice: Implementation of Family School Success for Parents of Children With ADHD

“Family-School Success” (FSS) is an efficacious intervention improving the home and school functioning of children with ADHD in grades 2–6. An extension of this intervention designed for a younger population also showed positive effects for kindergarten and first grade students in a pilot study. Following the completion of these trials, FSS was implemented in a fee-for-service tertiary care ADHD center. The implementation process included adapting the manual and treatment procedures to be feasible outside the structure and support of a federally funded randomized control trial (RCT). The current study examines the process of adapting the treatment protocol and examines the acceptability and effectiveness of the adapted FSS, as well as predictors of family treatment response including parent engagement in treatment (as measured by attendance and homework adherence). A case study illustrates the adaptations to the intervention and its implementation in the clinic-based setting. In line with findings from clinical trials, families reported high satisfaction with the adapted FSS intervention and showed significant improvement in parental self-efficacy, child academic homework performance, and reduction in child impairment. Additionally, as in the initial FSS RCT, parental attendance in the adapted FSS program predicted child attention to academic homework, controlling for parental adherence to between-session homework. Furthermore, controlling for attendance at FSS sessions, parent adherence to between-session homework assignments predicted improvements in parent self-efficacy as well as child’s homework productivity. These results replicate those of the original RCT and confirm that both session attendance and between-session homework completed are important for improvement during the program. Overall, this study provides support for the acceptability and effectiveness of this treatment model and suggests that future work toward dissemination to community-based settings would be worthwhile.     

Cognitive-Based Compassion Training: A Promising Prevention Strategy for At-Risk Adolescents

Compared to the general population, youth in foster care experience multiple psychosocial difficulties due to exceptionally high rates of maltreatment. Many youth in care receive psychological and/or psychotropic treatment but not all require or are willing to accept that level of intervention. For many, a “mental health” approach feels pathologizing. Nevertheless, these youth have suffered maltreatment and interventions to improve their ability to cope with past trauma and their often uncertain present are clearly needed. Cognitively-Based Compassion Training (CBCT) provides an alternative perspective on suffering and can be framed as a wellness intervention that is appropriate for all humans. The present study examined whether a 6-week CBCT intervention would improve psychosocial functioning among adolescents in foster care. Seventy adolescents were randomized to CBCT (twice weekly) or a wait-list condition. Youth were assessed at baseline and after 6 weeks. Groups did not differ on measures of psychosocial functioning following training; however practice frequency was associated with increased hopefulness and a trend for a decrease in generalized anxiety. Qualitative results indicated that participants found CBCT useful for dealing with daily life stressors. Adolescents in care were willing to engage in CBCT. The majority reported CBCT was very helpful and almost all reported they would recommend CBCT to a friend. Participants reported specific instances of using CBCT strategies to regulate emotion, manage stress, or to respond more compassionately towards others. Standardized self-report measures were not sensitive to qualitative reports of improved functioning, suggesting the need for measures more sensitive to the positive changes noted or longer training periods to demonstrate effects. Practical issues surrounding implementation of such programs in high-risk youth populations are identified. Recommendations are provided for further development.     

Lessons Learned from the National Arts and Youth Demonstration Project: Longitudinal Study of a Canadian After-School Program

We discuss some of the lessons the investigators learned during the development, implementation, and dissemination phases of the National Arts and Youth Demonstration Project (NAYDP). The lessons learned are relevant to various groups involved in large-scale, multi-site, community-based intervention studies: parents, youth, researchers, project staff, policy makers, and funders. Specific lessons learned include: (1) how to engage the community; (2) methodological lessons, including cross-site training and monitoring adherence to research protocol; (3) recruiting and sustaining involvement of parents and youth; (4) program development; and (5) dissemination strategies.     

Acting Locally and Globally: Dissemination Implementation Around the World and Next Door

Murray et al. (2014--this issue) present a fascinating account of their international dissemination and implementation (D&I) research focused on training therapists in Thailand and Iraq to provide a modular treatment approach called Common Elements Treatment Approach to youth. In this commentary, we use Murray et al. as a springboard to discuss a few general conclusions about the current direction of D&I research. Specifically, we reflect on current D&I models, highlighting their ecological focus and their emphasis on stakeholder involvement. Next, we discuss the central importance of implementation supports such as treatment programs, training approaches, assessment and outcome monitoring tools, and organizational interventions. We conclude with a consideration of how D&I work that aims to adapt implementation supports for local needs represent a key path to our goal of sustainability.     

The Treatment of Social Phobia in a Young Boy With Asperger's Disorder

Anxiety disorders, including social phobia, occur often in children with autism spectrum disorders (ASD; Gillott, Furniss, & Walter, 2001; Leyfer et al., 2006; Simonoff et al., 2008); however, little is known about the conceptualization and treatment of social phobia in this population. The current study presents the case of “James,” a 6-year-old male with comorbid Asperger's disorder and social phobia. A cognitive-behavioral treatment (CBT) package, including parent training, psychoeducation, graduated exposure, and reinforced practice, was implemented to decrease avoidance behaviors in social settings. Results showed that James's avoidance behaviors were reduced significantly following intervention, suggesting that a CBT approach may be effective in treating social phobia in children with ASD. The significant influence of CBT on decreasing avoidance behavior in comorbid social phobia and ASD highlights the need for continued investigation of adapting CBT for use with children with ASD.     

Increasing Youths’ Participation in Team-Based Treatment Planning: The <Emphasis Type="Italic">Achieve My Plan</Emphasis> Enhancement for Wraparound

Wraparound is a frequently implemented approach for providing individualized, community-based care for children and adolescents with serious mental health conditions and, typically, involvement in multiple child—and family-serving systems. Both Wraparound’s principles and its theory of change stress the importance of youths’ active participation throughout. However, research focusing on the experiences of youth in Wraparound indicates that they are often not particularly engaged in the process or participating actively with their teams, and the findings point to a lack of alliance between the young people and their teams. This article describes a randomized study testing the Achieve My Plan (AMP) enhancement for Wraparound, which is intended to increase young people’s satisfaction, active engagement and self-determined participation in Wraparound, as well as their alliance with the team. Study findings showed that, relative to youth who received “as usual” Wraparound, young people who received Wraparound with the AMP enhancement participated more—and in a more active and self-determined manner—with their teams. They also rated their alliance with their Wraparound teams significantly higher. Furthermore, adult team members in the intervention condition rated team meetings as being more productive, and they were more likely to say that the AMP meetings were “much better than usual” team meetings. Findings support the idea that it is possible—using a low-cost, low-“dose” intervention—to enhance young people’s self-determination and their engagement in Wraparound without detracting from team functioning or the satisfaction of other team members.