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Background Trauma narratives are a critical, exposure-based component of trauma-focused cognitive-behavioral therapy, yet community therapists rarely use them. Given evidence that intentions to deliver elements of cognitive behavioral therapy vary by component, and that intentions to deliver exposure are the weakest, this study focused specifically on trauma narratives. We drew on a social psychology causal theory (Theory of Planned Behavior (TPB)) and an implementation science framework (the Consolidated Framework for Implementation Research (CFIR)) to glean insight into multilevel influences on trauma narrative use. While the CFIR offers a broad list of factors potentially affecting implementation, the TPB offers causal pathways between individual-level constructs that predict behavior, including the uptake of an evidence-based intervention. The integration of these approaches may provide a more complete understanding of factors affecting therapists’ use of TNs. Methods Therapists (n=65) trained in trauma-focused cognitive behavioral therapy completed a survey about their use of and beliefs about trauma narratives. Content analysis was used to identify common beliefs about trauma narratives. A subset of participants (n=17) completed follow-up qualitative interviews, which were analyzed using an integrated approach informed by the CFIR. Results While most participants reported high intentions to use TNs, nearly half reported that they did not use TNs in the last 6 months. Survey data indicate a number of TPB-related determinants related to using trauma narratives. Qualitative interviews identified CFIR-relevant contextual factors that may influence constructs central to TPB. Conclusions These results highlight the importance of integrating approaches that address multiple theoretical determinants of therapist behavior, including therapist, organizational, and client factors with causal explanations to explain implementation behavior.

BACKGROUND: Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. METHODS: We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. RESULTS: In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. CONCLUSIONS: Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients’ access to effective treatment for anxiety disorders.

There is growing recognition that it is important to involve youth and caregivers in the implementation of evidence-based treatments (EBTs). This study explored how youth and caregivers who received trauma-focused cognitive-behavioral therapy (TF-CBT) in a public behavioral health system perceived the concept of EBT, their experience with treatment, their perceptions of TF-CBT, and whether their perceptions varied as a function of clinical improvement. Participants were eight youth (aged 10–17) and nine caregivers/legal guardians who received TF-CBT in community mental health centers. Semi-structured interviews were conducted post-treatment and symptoms were assessed at pre- and post-treatment. An integrated approach was used to analyze the interview data and the reliable change index was used to assess whether youth and caregivers’ impressions varied as a function of clinical improvement. Participants rarely had exposure to the term “evidence-based” and often had the misconception that evidence referred to personal experience. Youth and caregivers found the concept of receiving treatment supported by research appealing but did not like the specific term “evidence-based” and worried that treatment guided by research alone may not individualize to their needs. Personal stories were noted as a good way to market TF-CBT and the therapist emerged as an important advocate for promoting this treatment approach. Clinical improvement was associated with the perception of therapists as collaborative and with trauma narrative completion. Findings suggest that language and how therapists communicate EBTs to youth and caregivers may be important for targeted implementation strategies.

Objective Although Avoidant/Restrictive Food Intake Disorder (ARFID) has existed since the publication of DSM-5 in 2013, research on the descriptive psychopathology of treatment-seeking patients with formal ARFID diagnoses is sparse, and limited to tertiary eating disorder-focused treatment settings where most patients present with weight loss/malnutrition. In these settings, the selective/neophobic symptom presentation is rare compared to other primary eating restrictions. We aimed provide initial descriptive psychopathology of ARFID primary selective/neophobic symptom presentation in an outpatient setting, and to explore the prevalence of the core ARFID symptoms and clinical differences among patients meeting criteria based on weight/nutritional symptoms versus psychosocial impairment only. Method We reviewed the charts of 22 consecutive outpatients diagnosed with ARFID caused by selective/neophobic eating, and describe symptoms, impairment, illness trajectory, and demographic features. Patients who met ARFID criteria because of weight loss/nutritional problems were compared to those who met for psychosocial impairment only on demographic and clinical characteristics. Results Patients were predominantly male (81.8%) and school-aged (4-11 years). 81.8% had no weight/nutritional symptoms documented by a medical provider. All met criteria for significant psychosocial impairment. There were few differences between patients who did versus did not meet weight loss/nutritional criteria for ARFID; they differed only in age and in the presence of appetite disturbances consistent with another proposed presentation of ARFID. Discussion These results provide novel data on the clinical characteristics of individuals who present with a primary presentation of selective/neophobic ARFID, including support for psychosocial impairment as sufficient for fulfilling ARFID criterion A.

Although a number of trauma treatments for youth have demonstrated efficacy in research settings, the promise of these treatments has not yet been realized via widespread implementation in usual care settings. Implementation science, the scientific study of methods to increase the adoption, uptake, and sustainment of evidence-based practices (EBPs), can help to inform this research-to-practice gap. This chapter applies principles from implementation science to review what has been learned so far about the dissemination and implementation of EBPs for youth impacted by trauma in the United States and the next steps for this field. First, the chapter describes the large-scale efforts that have been made in the United States to disseminate and implement these EBPs. Second, it applies an implementation science framework, the exploration, preparation, implementation, and sustainment framework, to organize what has been learned from these efforts about barriers and facilitators to implementation and sustainability. Third, a case study is presented illustrating how this knowledge was applied to develop a trauma-informed system of care in Philadelphia. Finally, the chapter offers research and practical recommendations to improve the dissemination and implementation of EBPs for trauma-affected youth.

Objectives Although turnover, defined as when a therapist leaves his/her organization, occurs frequently in public mental health organizations, its impact on clients is understudied. This study examined the effects of turnover on client engagement among youth receiving services in one public mental health agency. Methods Data were abstracted through a retrospective chart review of 76 clients who initiated outpatient trauma-focused treatment with 30 therapists between June 2013 and January 2016 at one agency in Philadelphia. Client demographic information, client session attendance, and therapist for each session was abstracted from each chart. The dependent variable (i.e., client engagement) was operationalized as client attendance to scheduled sessions. Mixed-effects regression analyses were used. Results Youth who experienced therapist turnover were 86% more likely to miss a future scheduled therapy session. When exploring this effect by diagnosis, youth without a Post-Traumatic Stress Disorder (PTSD) diagnosis were more likely to miss a scheduled session following therapist turnover than those with a PTSD diagnosis (p Conclusions Therapist turnover is a strong predictor of client engagement among youth receiving trauma-focused treatment, and a PTSD diagnosis may be a protective factor against missing sessions. Implications for treatment planning in the face of therapist turnover are discussed.

Urban youth have high rates of traumatic exposures; 16% of youth eventually develop Post-Traumatic Stress Disorder (PTSD). Though it is critical for urban youth living in poverty to have access to evidence-based interventions for traumatic stress in their community settings, there is limited research on the effectiveness of these interventions when provided in these settings. The objectives of the current study are to 1) evaluate the effectiveness of Trauma-Focused Cognitive Behavioral Therapy delivered from 2013–16 in 15 behavioral health agencies on youth (N = 114) PTSD (measured by the Child PTSD Symptom Scale (CPSS)) and general mental health symptoms (measured by the Ohio Mental Health Consumer Outcomes System (Ohio Scales)) and 2) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health system; a system that has invested significantly in the training and ongoing support of clinicians providing high quality trauma services to youth since 2012. From baseline to last assessment, youth outcomes improved on the following measures: CPSS symptom severity (d = .34), CPSS functional impairment (d = .38), and the Ohio Scales overall mental health problem severity (d = .29). The effect sizes for symptom improvement were smaller than the effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF-CBT, and provides preliminary findings with regards to the effectiveness, and transportability, of TF-CBT in urban community settings that serve youth in poverty.

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder (PTSD), TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study—drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia—we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants’ addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p >0.05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Anxiety disorders are common in children and adolescents with autism spectrum disorder (ASD), yet difficult to disentangle from features of ASD itself. Challenges to assessment include symptom overlap, the varied manifestation of some anxiety symptoms, and the limitations of self-report. Nonetheless, a growing body of research suggests that it is both possible and important to reliably differentiate anxiety and ASD pathology. Anxiety disorders are associated with a number of additive difficulties in youth with ASD. Emerging evidence also suggests that these difficulties—when identified—can be effectively treated in cognitively-able youth with cognitive-behavioral methods. The present article will provide a clinical framework for diagnosing anxiety disorders in cognitively-able youth on the autism spectrum, with a particular emphasis on differentiating anxiety and ASD symptoms. We will review recent research on the presentation, measurement, and predictors of anxiety in ASD, provide an overview of the pros and cons of available measures and illustrate approaches for differential diagnosis via vignettes of actual clinical assessments.

There is a dearth of knowledge on trichotillomania in youth, which is particularly problematic given that trichotillomania typically develops in childhood or early adolescence. Early identification and treatment may prevent adult morbidity and impairment. This paper presents the rationale, design, and methods of a randomized controlled trial (RCT) that will investigate the efficacy of behavior therapy (BT) vs. supportive counseling (SC) for youth (ages 10–17) with trichotillomania (TTM). This study seeks to replicate and extend findings from a smaller RCT which compared BT to a minimal attention control condition and indicated an advantage for BT. Participants will be randomized to BT or SC. After eight weeks of treatment, participants in the BT condition will enter an eight week maintenance phase and participants in the SC condition will be offered BT. The primary aim is to examine the effect of treatment on TTM symptom reduction at post-treatment. Secondary aims include evaluation of the maintenance of BT gains through a naturalistic follow-up phase, predictors of acute and long-term response to BT (including psychiatric comorbidity, initial severity, family psychopathology, and pulling subtype), and the efficacy of BT for patients who initially receive SC, and to benchmark those outcomes against those achieved by patients who are initially randomized to BT. Given how little research has been devoted to pediatric TTM and its treatment, this study represents an essential step in identifying and implementing efficacious treatments for youth with TTM.

BACKGROUND: Although exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness. METHODS: Participants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation. RESULTS: Experiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up. CONCLUSIONS: A one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions. TRIAL REGISTRATION: Clinicaltrials.gov: NCT0335497

Author(s): Kratz, Hilary E; Stahmer, Aubyn; Xie, Ming; Marcus, Steven C; Pellecchia, Melanie; Locke, Jill; Beidas, Rinad; Mandell, David S | Abstract: OBJECTIVE:An organization's implementation climate, or the extent to which use of an intervention is expected, supported, and rewarded by colleagues and supervisors, has been identified as critical to successful intervention implementation and outcomes. The effect of implementation climate has not been well studied in special education settings. The present study examines the association between teachers' perceptions of implementation climate, teacher fidelity to a school-based program for students with autism, and student outcomes (measured as changes in IQ) over time. METHOD:Participants included 158 students from 45 classrooms and their teachers. Teachers provided a measure of implementation climate at the beginning of the academic year; program fidelity was measured monthly throughout the year. The main and interaction effects of perceived implementation climate and fidelity on student outcomes were examined using longitudinal nested linear models with random effects for classroom and student, controlling for important covariates. RESULTS:On average, IQ scores improved 2.2 points (SD = 8.7). There were no main effects of perceived implementation climate or fidelity on student outcomes; however, the interaction between perceived implementation climate and fidelity was associated with student outcomes (p l .05, d = 0.54). Among classrooms with a strong perceived implementation climate, higher fidelity was associated with better student outcomes. CONCLUSIONS:While preliminary and requiring replication, these findings suggest that perceived implementation climate and program fidelity each may be important but not sufficient for optimizing outcomes for students with autism. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been the subject of much study over the past fifteen years. Building on a foundation of case studies and open clinical trials, the literature now contains many methodologically sound studies that have compared full CBT protocols to waitlist controls, pill placebo, psychosocial comparison conditions, active medication, combined treatments, and brief CBT. This review is part of a series commissioned by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) in an effort to publish in one place what is known about the efficacy of treatments for OCD. A total of fourteen studies were identified; collectively their findings support the efficacy of CBT for youth with OCD. CBT protocols that emphasized either strictly behavioral or cognitive conceptualizations have each been found efficacious relative to waitlist controls. Efforts to enhance CBT׳s efficacy and reach have been undertaken. These trials provide guidance regarding next steps to be taken to maximize efficacy and treatment availability. Findings from studies in community clinics suggest that significant treatment benefits can be realized and are not reported only from within academic contexts. These findings bode well for broader dissemination efforts. Recommendations for future research directions are provided.

Despite the abundance of research that supports the efficacy of exposure therapy for childhood anxiety disorders and OCD, negative views and myths about the harmfulness of this treatment are prevalent. These beliefs contribute to the underutilization of this treatment and less robust effectiveness in community settings compared to randomized clinical trials. Although research confirms that exposure therapy is efficacious, safe, tolerable, and bears minimal risk when implemented correctly, there are unique ethical considerations in exposure therapy, especially with children. Developing ethical parameters around exposure therapy for youth is an important and highly relevant area that may assist with the effective generalization of these principles. The current paper reviews ethical issues and considerations relevant to exposure therapy for children and provides suggestions for the ethical use of this treatment.

Exposure to traumatic experiences among youth is a serious public health concern. A trauma-informed public behavioral health system that emphasizes core principles such as understanding trauma, promoting safety, supporting consumer autonomy, sharing power, and ensuring cultural competence, is needed to support traumatized youth and the providers who work with them. This article describes a case study of the creation and evaluation of a trauma-informed publicly funded behavioral health system for children and adolescents in the City of Philadelphia (the Philadelphia Alliance for Child Trauma Services; PACTS) using the Exploration, Preparation, Implementation, and Sustainment (EPIS) as a guiding framework. We describe our evaluation of this effort with an emphasis on implementation determinants and outcomes. Implementation determinants include inner context factors, specifically therapist knowledge and attitudes (N = 114) towards evidence-based practices. Implementation outcomes include information on rate of PTSD diagnoses in agencies over time, number of youth receiving TF-CBT over time, and penetration (i.e., number of youth receiving TF-CBT divided by the number of youth screening positive on trauma screening). We describe lessons learned from our experiences building a trauma-informed public behavioral health system in the hopes that this case study can guide other similar efforts.

© The Author(s) 2014 This study sought to validate a new measure, the Classroom Cohesion Survey (CCS), designed to examine the relationship between teachers and classroom assistants in autism support classrooms. Teachers, classroom assistants, and external observers showed good inter-rater agreement on the CCS and good internal consistency for all scales. Simple factor structures were found for both teacher- and classroom assistant–rated scales, with one-factor solutions for both scales. Paired t tests revealed that on average, classroom assistants rated classroom cohesion stronger than teachers. The CCS may be an effective tool for measuring cohesion between classroom staff and may have an important impact on various clinical and implementation outcomes in school settings.