Jason E. Chapman

Juvenile Drug Court: Enhancing Outcomes by Integrating Evidence-Based Treatments.

Evaluated the effectiveness of juvenile drug court for 161 juvenile offenders meeting diagnostic criteria for substance abuse or dependence and determined whether the integration of evidence-based practices enhanced the outcomes of juvenile drug court. Over a 1-year period, a four-condition randomized design evaluated outcomes for family court with usual community services, drug court with usual community services, drug court with multisystemic therapy, and drug court with multisystemic therapy enhanced with contingency management for adolescent substance use, criminal behavior, symptomatology, and days in out-of-home placement. In general, findings supported the view that drug court was more effective than family court services in decreasing rates of adolescent substance use and criminal behavior. Possibly due to the greatly increased surveillance of youths in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in rearrest or incarceration. In addition, findings supported the view that the use of evidence-based treatments within the drug court context improved youth substance-related outcomes. Clinical and policy implications of these findings are discussed.

Toward the Effective and Efficient Measurement of Implementation Fidelity

Implementation science in mental health is informed by other academic disciplines and industries. Conceptual and methodological territory charted in psychotherapy research is pertinent to two elements of the conceptual model of implementation posited by Aarons and colleagues (2010)—implementation fidelity and innovation feedback systems. Key characteristics of scientifically validated fidelity instruments, and of the feasibility of their use in routine care, are presented. The challenges of ensuring fidelity measurement methods are both effective (scientifically validated) and efficient (feasible and useful in routine care) are identified as are examples of implementation research attempting to balance these attributes of fidelity measurement.

Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy.

OBJECTIVEnA randomized trial assessed the effectiveness of a 2-level strategy for implementing evidence-based mental health treatments for delinquent youth.nnnMETHODnA 2 x 2 design encompassing 14 rural Appalachian counties included 2 factors: (a) the random assignment of delinquent youth within each county to a multisystemic therapy (MST) program or usual services and (b) the random assignment of counties to the ARC (for availability, responsiveness, and continuity) organizational intervention for implementing effective community-based mental health services. The design created 4 treatment conditions (MST plus ARC, MST only, ARC only, control). Outcome measures for 615 youth who were 69% male, 91% Caucasian, and aged 9-17 years included the Child Behavior Checklist and out-of-home placements.nnnRESULTSnA multilevel, mixed-effects, regression analysis of 6-month treatment outcomes found that youth total problem behavior in the MST plus ARC condition was at a nonclinical level and significantly lower than in other conditions. Total problem behavior was equivalent and at nonclinical levels in all conditions by the 18-month follow-up, but youth in the MST plus ARC condition entered out-of-home placements at a significantly lower rate (16%) than youth in the control condition (34%).nnnCONCLUSIONSnTwo-level strategies that combine an organizational intervention such as ARC and an evidence-based treatment such as MST are promising approaches to implementing effective community-based mental health services. More research is needed to understand how such strategies can be used effectively in a variety of organizational contexts and with other types of evidence-based treatments.

Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial

Despite the serious and costly problems presented by juvenile sexual offenders, rigorous tests of promising interventions have rarely been conducted. This study presents a community-based effectiveness trial comparing multisystemic therapy (MST) adapted for juvenile sexual offenders with services that are typical of those provided to juvenile sexual offenders in the United States. Youth were randomized to MST (n = 67) or treatment as usual for juvenile sexual offenders (TAU-JSO; n = 60). Outcomes through 12 months postrecruitment were assessed for problem sexual behavior, delinquency, substance use, mental health functioning, and out-of-home placements. Relative to youth who received TAU-JSO, youth in the MST condition evidenced significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements. The findings suggest that family- and community-based interventions, especially those with an established evidence-base in treating adolescent antisocial behavior, hold considerable promise in meeting the clinical needs of juvenile sexual offenders.

Mediators of Change for Multisystemic Therapy with Juvenile Sexual Offenders

The mediators of favorable multisystemic therapy (MST) outcomes achieved at 12 months postrecruitment were examined within the context of a randomized effectiveness trial with 127 juvenile sexual offenders and their caregivers. Outcome measures assessed youth delinquency, substance use, externalizing symptoms, and deviant sexual interest/risk behaviors; hypothesized mediators included measures of parenting and peer relations. Data were collected at pretreatment, 6 months postrecruitment, and 12 months postrecruitment. Consistent with the MST theory of change and the small extant literature in this area of research, analyses showed that favorable MST effects on youth antisocial behavior and deviant sexual interest/risk behaviors were mediated by increased caregiver follow-through on discipline practices as well as decreased caregiver disapproval of and concern about the youths bad friends during the follow-up. These findings have important implications for the community-based treatment of juvenile sexual offenders.

Clinical Supervision in Treatment Transport: Effects on Adherence and Outcomes

This nonexperimental study used mixed-effects regression models to examine relations among supervisor adherence to a clinical supervision protocol, therapist adherence, and changes in the behavior and functioning of youths with serious antisocial behavior treated with an empirically supported treatment (i.e., multisystemic therapy [MST]) 1 year posttreatment. Participants were 1,979 youths and families treated by 429 clinicians across 45 provider organizations in North America. Four dimensions of clinical supervision were examined. Mixed-effects regression model results showed that one dimension, supervisor focus on adherence to treatment principles, predicted greater therapist adherence. Two supervision dimensions, Adherence to the Structure and Process of Supervision and focus on Clinician Development, predicted changes in youth behavior. Conditions required to test hypothesized mediation by therapist adherence of supervisor adherence effects on youth outcomes were not met. However, direct effects of supervisor and therapist adherence were observed in models including both of these variables.

A Survey of the Infrastructure for Children’s Mental Health Services: Implications for the Implementation of Empirically Supported Treatments (ESTs)

A structured interview survey of directors of a large national sample (nxa0=xa0200) of mental health service organizations treating children examined the governance, financing, staffing, services, and implementation practices of these organizations; and, director ratings of factors important to implementation of new treatments and services. Descriptive analyses showed private organizations financing services with public (particularly Medicaid) funds are prevalent and that employment of professional staff, clinical supervision and training, productivity requirements, and outcomes monitoring are common. Results of random effects regression models (RRMs) evaluating associations between governance, financing, and organizational characteristics and the use of new treatments and services showed for-profit organizations more likely to implement such treatments, and organizations with more licensed clinical staff and weekly clinical supervision in place less likely to do so. Results of RRMs evaluating relations between director ratings of the importance to new treatment and service implementation of three factors—fit with existing implementation practices, infrastructure support, and organizational mission and support—suggest greater importance to public than private organizations of these factors. Implications for EST implementation and future research are described.

Statewide Adoption and Initial Implementation of Contingency Management for Substance Abusing Adolescents

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted.

Therapist Adherence and Organizational Effects on Change in Youth Behavior Problems One Year After Multisystemic Therapy

The current study investigated the relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior (i.e., Multisystemic Therapy), organizational climate and structure, and improvement in youth behavior problems one-year post treatment. Participants were 1979 youth and families treated by 429 therapists across 45 provider organizations in North America. Hierarchical Linear Modeling (HLM) results showed therapist adherence predicted improvement in youth behavior. Two structure variables and one climate variable predicted changes in youth behavior, and the climate variable also predicted therapist adherence. No statistical support for formal mediation of organizational effects through adherence was found, though examination of changes in parameter estimates suggest a possible interplay of organizational climate with adherence and youth behavior change.

Using Session-by-Session Measurement to Compare Mechanisms of Action for Acceptance and Commitment Therapy and Cognitive Therapy

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive defusion (the ability to see ones thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.