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There remains a need for a disorder-specific inventory of children’s depression and anxiety that can reliably screen anxious and depressive disorder symptomatology in Chinese children. The Revised Child and Anxiety Depression Scale (RCADS) is a self-report questionnaire assessing anxiety and depression in children (Chorpita et al., 2000; Piqueras et al., 2017). This study sought to evaluate its psychometric properties in a Mainland Chinese sample. Students from the 4th to 11th grades (N = 1001) participated in this study. Each of the RCADS subscales, by age and sex, possessed reliability coefficients ranging between .63 and .81. Means and standard deviations for RCADS subscales calculated for the age and sex sub-samples were reported. Participants reported slightly lower levels on five subscales than for Chorpita et al. (2000) normative sample. The scales were significantly and strongly correlated with the Child Behavior Checklist (CBCL) subscales (somatic, withdrawal, anxiety) as well as CBCL internalizing scores. Fit statistics suggested marginal to adequate fit for the six-factor model for the Chinese youth. The present study provides foundational support for the psychometric properties of the RCADS in a large sample of Chinese youth yet indicates that factor structure might be improved through enhanced sampling of culturally relevant symptom expressions.

BackgroundPsychotherapy implementation must contend with the task of preparing a mental health workforce to provide the highest quality services to as much of a service population as possible, in high-income as well as low-to-middle income countries.ObjectiveWe outline general challenges and solutions and investigate how well various implementation strategies would fit a clinical population.MethodsUsing a data set from a prior cluster randomised trial with a clinically diverse population and 33 intervention practices, we presented multiple illustrations comparing the ability of different implementation strategies to serve youth and families with procedures in which service providers were trained.FindingsA series of survival functions demonstrated that many common implementation strategies are unlikely to create a prepared workforce, given the large and diverse number of practices needed to be mastered by providers.Clinical implications‘Benchmark’ solutions that afforded superior coverage of the service population could be supported through paced learning approaches (ie, training interventions a little at a time) using extensible, modular intervention designs.

Consultation-liaison services are an integral part of many pediatric hospital settings, yet characteristics of this patient population have not been extensively documented. The current study is a retrospective one-year chart review of the consultation-liaison service at a large pediatric hospital in the Southwestern United States. The purpose of this study is twofold: (1) to characterize this hospital’s CL population and (2) to use these characteristics to identify preliminary evidence-based practices that should be considered for CL provider training. Identifying evidence-based practice elements that align with the characteristics of consultation–liaison patient populations may inform trainings for consultation-liaison staff. This would help to ensure that youth seen in hospital consultation-liaison services are getting the best available services, which is critical given the shortened time frame available to work with this patient population.

Successful innovations inevitably evolve over time. Such change presents challenges for implementation, especially given that the contexts interacting with the innovation are evolving too. We discu...

This pilot study aimed to evaluate the relevance, feasibility, acceptability, and instructional efficacy of the Managing and Adapting Practice (MAP) curriculum for enhancing the teaching of psychotherapy to child and adolescent psychiatry (CAP) fellows. MAP is a system of resources and decision models that supports practitioners in selecting and implementing psychotherapeutic interventions for children and adolescents. The MAP curriculum includes modules to guide education about psychotherapeutic procedures (e.g., behavioral activation) common in evidence-based treatments for an array of childhood problems and to support development of competencies in assessment, treatment planning, and reflective practice.Curriculum coding was used to examine the relevance of MAP's core components to the skills articulated in the Accreditation Council for Graduate Medical Education (ACGME) CAP milestones. Feasibility, acceptability, and learning outcomes were examined after delivery of the MAP curriculum to 12 CAP fellows at two sites, with instructional features tailored according to faculty preferences and training program structure.Coding suggested that the MAP curriculum was relevant to 95% of the 21 ACGME CAP training subcompetencies. Feasibility was indicated by the successful delivery of 100% of the planned MAP curriculum across the two sites. Acceptability was supported by positive feedback from the CAP fellows, and psychotherapy knowledge increased significantly. Finally, case review scores (mean±SD=2.21±0.15) showed positive posttraining application of MAP to two patients and exceeded scores achieved by other samples of mental health professionals.This pilot study demonstrated the potential for the MAP curriculum to support CAP education. MAP's versatility as a curriculum supports broader adoption, with continuing rigorous empirical evaluation.

The Agency Supervisor training model, which accentuates the training function of clinical supervision, is an innovative strategy for scaling evidence-informed behavioral health services. The presen...

There is strong enthusiasm for utilizing implementation science in the implementation of evidence-based programs in children's community mental health, but there remains work to be done to improve the process. Despite the proliferation of implementation frameworks, there is limited literature providing case examples of overcoming implementation barriers. This article examines whether the use of three implementations strategies, a structured training and coaching program, the use of professional development portfolios for coaching, and a progress monitoring data system, help to overcome barriers to implementation by facilitating four implementation drivers at a community mental health agency. Results suggest that implementation is a process of recognizing and adapting to both predictable and unpredictable barriers. Furthermore, the use of these implementation strategies is important in improving implementation outcomes.

Background\ud Adolescents in low and middle-income countries experience pronounced mental health needs in contexts where infrastructure and resources are scarce. While evidence-based treatment are readily available, they may not fit the unique needs of certain contexts.\ud \ud Objective\ud This manuscript illustrates the systematic process of applying ‘relevance mapping’ methodology to leverage the youth mental health evidence base to identify candidate practices for inclusion in the development of a contextually appropriate psychological treatment protocol for common adolescent mental health problems in India.\ud \ud Methods\ud The practice identification was informed by two datasets obtained from adolescent samples in India. The first was an epidemiological dataset from a large community sample in Goa (N = 2,048); the second incorporated ‘youth top problems’ reported by service-seeking students presenting to school counsellors in Goa and Delhi (N = 78). Problems identified in each dataset were categorized using structured codes. Problem codes and youth demographics were then indexed against a database of hundreds of evidence-based psychological treatments and their associated clinical trials. This methodology revealed the most common practice elements (discrete therapeutic strategies) and their most efficient combinations with evidence of effectiveness matching the demographics and diagnostic category (anxiety, disruptive behaviors and depression) prevalent in the planned treatment population.\ud \ud Results\ud For anxiety, the most common practice elements for this age group were exposure, cognitive coping, and psychoeducation. For disruptive behaviors, the most common practices were problem-solving, goal-setting, and rapport-building. For depression, cognitive coping, behavioral activation, and psychoeducation were the most common practice elements.\ud \ud Conclusion\ud These practice elements provided the treatment development team with a preliminary list of candidate content for the development of an intensive psychological treatment within a stepped care service model to address common adolescent mental health problems in schools in India.

The evidence-base services literature is continually growing, providing the field with rich and important sets of information regarding what works for treating different types of youth and families. Given this burgeoning of information, the PracticeWise Evidence-Based Services (PWEBS) Literature Database has been developed to aid in summarizing and delivering aggregated evidence-based treatment information to providers in the field. Meanwhile, the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) Scale is a youth mental health assessment tool that was developed by a separate team to assist with treatment planning. In the present study, we developed and tested a system for linking these two related ontological systems so that scientific knowledge can be more widely aggregated and made available to a wider set of audiences for enhanced mental health service delivery. Results revealed the following. First, a construct mapping comparison revealed that the CANS-MH and PWEBS ontologies share a strong core of overlapping content, particularly in the areas of Youth Behavioral/Emotional Needs, Youth Risk Behaviors, and Life Domain Functioning. Second, the CANS-MH areas were able to be used to reliably code the following components of published randomized treatment studies: (a) population sample characteristics (e.g., did the characteristics of the treatment study participant population relate to each CANS-MH area?), and (b) outcome measure targets (e.g., did the treatment study outcome measure target areas relate to each CANS-MH area?). The reliability achieved from this coding process supported the linkage between the CANS-MH areas and the PWEBS Literature Database information. Lastly, high agreement was achieved between an automated translation algorithm and the final ratings from the manual coding of published treatment studies using the CANS-MH scale. The importance of such linkages for the communication of ideas, information, and evidence across differing subfields is discussed, as well as examples of achieving enhanced quality of mental health services by linking system ontologies.

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

This discussion article begins by highlighting two trends apparent in the field of child maltreatment. The first, an awareness that multiple forms of maltreatment – polyvictimization - is the rule in populations of abused and neglected children rather than the exception. The second is that current types of child maltreatment are being extended to include Adverse Childhood Experiences (ACEs). These include intra-familial violence, mental health, substance misuse, and inter-generational abuse. The paper introduces an innovative strategy to help the field better organise and prevent the extensive sequelae of polyvictimization and ACEs. This strategy involves the development of a modular approach, which identifies common treatment elements and common factors across the field of effective interventions and organizes them, providing a co-ordinated framework for practitioners to use to address the diverse needs of children and families when vulnerability or maltreatment are identified. The development of this approach, the Hope for Children and Families (HfCF) Intervention Resources, is described using a case example to illustrate its logic and structure. Findings from the HFCF pilot and subsequent training programs suggest that this new approach could be an important milestone in the protection of children from violence, abuse and neglect on the 30th Anniversary of the United Nation’s Convention on the Rights of the Child (1989).

This study examined providers' reflections on delivering managing and adapting practice (MAP), an evidence-informed framework that guides decision-making from scientific and client data. Consensual qualitative research methods were used to analyze the reflections of 201 youth mental health providers. Results indicated that providers approached MAP according to their own preferences and particular cases. While most appeared to approach MAP from a practice management standpoint, when faced with challenging cases, providers used coordination and outcomes management resources. Regardless of approach, most providers came to appreciate the full framework through reflective practice. Their diverse approaches offer lessons for evidence-based practice implementation and sustainment.

We investigated whether a service-planning document outlining recommendations for what providers should address in treatment (i.e., targets) and the associated clinical techniques they should employ (i.e., practices) influenced the targets and practices that providers reported actually implementing during the subsequent treatment episode. Participants included 94 youths ages 4 to 17 (M=13.57, SD=3.59) who received community-based mental health services from the Hawai'i Child and Adolescent Mental Health Division. Data on targets and practices were compared across initial Mental Health Treatment Plans and Monthly Treatment and Progress Summaries. Data were analyzed using two-level, generalized mixed effects models with two-way cross-classification or linear mixed effects models. Providers were more likely to report the use of targets and practices in treatment if they were included within the treatment plan. In addition, the more closely targets addressed during treatment followed the recommended targets from the treatment plan, the more closely implemented practices followed the recommended practices listed in the treatment plan. Furthermore, as providers shifted their focus to different targets, a shift in their use of practices was also evident over time. Last, practices for which there is demonstrated efficacy for particular targets were more likely to be used. Service planning documents appear to help organize care; however, results also suggest possible limitations to the current system. These findings highlight potential areas for improvement in planning and care delivery.

Introduction Strategies are needed to improve the efficacy of paraprofessional home visitors for pregnant women in the United States. This study evaluates the maternal and child outcomes when evidence-based practices (EBP) are replicated with flexibility, rather than fidelity to a manualized intervention. Methods Pregnant mothers (N = 203) in five clinics were recruited in the waiting rooms and randomized to standard clinic care as the control condition (n = 104) or standard care plus home visiting (n = 99). Home visitors (n = 9) were selected, trained in foundational skills common to EBP and four problem domains (weight control, breastfeeding, daily habits, and depression). Independent interviewers assessed targeted outcomes at birth (82%) and 6 months later (83%). Results: Home visitors, called Mentor Mothers [MM], made an average of 14.9 home visits or telephone contacts (SD = 9; total contacts = 1491) addressing maternal daily habits, breastfeeding, and depression. Intervention and control mothers were similar in weight, Body Mass Index (BMI), depression and social support at baseline and 6 months later. The percentage of low birth weight babies was similar; intervention infants’ growth (weight/height Z score) tended to be significantly better compared to the control condition. Discussion: There are many explanations for the failure to find significant benefits: insufficient statistical power; the benefits of repeated assessments by warm, supportive peers to improve outcomes; or the failure of EBP and the need to maintain replication with fidelity. All study mothers had better outcomes than documented among comparable published samples of low-income, Latina and Korean–American mothers in Los Angeles, CA. ClinicalTrials.gov registration NCT01687634.

This paper describes a strategy for using evidence-based interventions (EBI) that does not require replication and fidelity. Eight parents, identified as positive role models, conducted home visits for 101 low-income Latina and Korean pregnant women. The home visitors, called mentor mothers (MM), were trained in 10 of the practice elements common to 80% of child-focused EBI and how to apply these skills to support mothers in obesity prevention, to increase the duration of breastfeeding, and to reduce depression. MM reported the content and skills utilized on each home visit on mobile phones. Each MM made an average of 153 home visits (SD=173.3), with 28 of these visits being phone contacts. Body mass index (BMI) at 6months was significantly associated with the frequency of MM focused on coping with depression (r=.24), but was not related to practice elements used by MM. The duration of breastfeeding was significantly related to the frequency with which MM focused on the topic of breastfeeding (r=.28) and parenting (r=.3), and MM use of attending (r=.24) and relaxation (r=.27). Depression was significantly correlated with the frequency of addressing depression (r=.27), but not to practice elements. MM did use different strategies in the first 150 visits compared to their last 150 visits, reflecting data-informed supervision. Evidence synthesized from EBI was used as a novel training method, with real-time monitoring and data-informed supervision providing evidence of iterative quality improvements in MM behaviors over time, as well as a way for linking implementation processes to outcomes.

The Patient Protection and Affordable Care Act (ACA, 2010) will have a remarkable impact on mental health services, yet enormous implementation challenges exist. This commentary examines some of the issues related to workforce development and performance measures raised by Chor, Olin, and Hoagwood (2014). In particular, we examine inefficiencies related to the Mental and Behavioral Health Education and Training Grants, current training models, national initiatives to identify consensus quality indicators, and electronic health records. We highlight opportunities for psychology to lead effective reform by developing efficient training and knowledge architectures.

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform children's mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of "common elements" of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.

Concerns about the gap between service quality in mental health systems and the growing literature on scientifically tested treatment approaches has led to multiple policy and practice initiatives calling for greater use of empirically supported interventions (ESIs) in children’s mental health systems. Despite the demonstrated efficacy of these approaches, some concerns remain about the current suitability of ESIs as a single strategy for improving service system quality. Issues raised include (a) the appropriateness of some interventions for individualized care or adaptation in response to emergent events, and (b) the ability for ESIs collectively to yield a comprehensive service array for youth and families. The current paper thus outlines one strategy to complement and extend that work, through a system for organizing and coordinating currently available ESIs as well as for building and adjusting individualized, evidence-informed plans when needed, using dedicated tools to inform treatment design, adaptation, and evaluation in real time. A case example is presented, and implications for treatment and research are discussed.

We describe the scaling up of an evidence-informed model of care, Managing and Adapting Practice (MAP) in Los Angeles County, California. MAP complemented an array of evidence-based programs selected by the county as part of a large system reform effort designed to improve care for children and adolescents. In addition, we discuss the MAP model for training therapists and present data both on how the training model performed and on the outcomes of youths treated by therapists trained in MAP. We examined the success of two different training pathways for MAP therapists: (a) national training model and (b) MAP agency supervisor model (i.e., train the trainer). We also examined utilization of MAP and outcomes of clients served by MAP. Both the national training and MAP agency supervisor model were successful in producing MAP therapists in a timely fashion and with acceptable competency scores. Furthermore, a large number of clients were receiving MAP services. Finally, outcomes for youth treated with MAP were strong, with effect sizes ranging from .59 to .80 on the Youth Outcome Questionnaire. These data support the notion that scaling up a mental health services approach in a system can be achieved through a strong and broad partnership among relevant stakeholders, can involve a train-the-trainer model, and can result in strong outcomes for clients.

This study investigated whether and which evidence-based treatment (EBT) components might generalize to youths served by the wraparound process. To examine these questions, the study used relevance mapping, an empirical methodology that compares youths in a given clinical population with participants in published randomized trials to determine who may be "coverable" by EBTs and which treatments may collectively be most applicable. In a large diverse clinical sample, youths receiving wraparound services (n = 828) were compared with youths receiving other services (n = 3,104) regarding (a) demographic and clinical profiles, (b) "coverability" by any EBTs, and (c) specific practices from those EBTs that most efficiently applied to each group. Participants in studies of EBTs matched the demographic and clinical characteristics of nearly as many youths receiving wraparound (58-59%) as those receiving non-wraparound services (61-64%). Moreover, the best-fitting solutions of relevant sets of practices were highly similar across groups. These results provide the first large-scale empirical characterization of fit between EBTs and youths receiving wraparound and suggest that these youths are well suited to benefit from clinical strategies commonly used in EBTs.

Using the distillation component of the Distillation and Matching Model framework (Chorpita, Daleiden, & Weisz, 2005 ), we examined which engagement practices were associated with three domains of treatment engagement: attendance, adherence, and cognitive preparation (e.g., understanding of, readiness for treatment). Eighty-nine engagement interventions from 40 randomized controlled trials in children' s mental health services were coded according to their engagement practices and outcomes. Analyses examined whether the practices used in successful interventions differed according to engagement domain. Practice patterns differed somewhat depending on whether attendance, adherence, or cognitive preparation was the outcome of interest. For example, assessment of barriers to treatment frequently occurred in successful interventions targeting attendance, whereas homework assignment frequently occurred in successful interventions when adherence was the target outcome. Modeling and expectation setting were frequently used in successful interventions targeting cognitive preparation for treatment. Distillation provides a method for examining the practice patterns associated with different engagement outcomes. An example of the application of these findings to clinical practice includes using certain practices (e.g., assessment, psychoeducation about services, and accessibility promotion) with all youth and families to promote attendance, adherence, and cognitive preparation. Then, other practices (e.g., modeling, homework assignment) can be added on an as-needed basis to boost engagement or to address interference in a particular engagement domain. The use of a distillation framework promotes a common language around engagement and highlights practices that lend themselves well to training, thereby promoting the dissemination of engagement interventions.

This article presents a broad-based framework for evaluating integrity, defined as the structured comparison of observed values (i.e., what did happen) with expected values (i.e., what should happen), across various domains (e.g., practices, outcomes) for the purposes of informing key questions in system contexts (e.g., Is a practice being done properly? How well is it working?). We discuss the application of integrity in serving the goals of the scientific and service systems and potential sources for observed and expected values. An expanded framework regarding integrity analysis is presented detailing multiple domains of measurement (e.g., outcomes, activities, and resources), types of analysis (e.g., across vs. within units), and levels of analysis (e.g., event, episode, multi-episode). Other possible applications of integrity analysis in service systems and ongoing dissemination and implementation efforts are also discussed.

The current study examined the extent to which usual care interventions targeting childhood traumatic stress involved the application of practice elements (Chorpita, Daleiden, & Weisz, 2005) represented among the evidenced-based treatments (EBTs) for trauma. Youth age and the presence of conduct problems at intake were examined as potential predictors of differences in the presence of elements from EBTs. Data were obtained from archival records from 814 youth who received services from a large, community-based mental health system. Results showed that usual care clinicians reported a variety of practices, only some of which were common to the evidence base for traumatic stress. ‘Exposure’ stood out as the most common practice element among EBTs for treating traumatic stress, but it was reported in fewer than a quarter of usual care cases. For youth receiving out-of-home services, a diagnosis of PTSD predicted that fewer practice elements from EBTs for trauma were reported. Also, as youth age increased, clinicians reported using more practice elements from the evidence base. These findings point to possible opportunities for service improvement in usual care settings for trauma-exposed youth and at the same time call into question whether aspects of the context or population warrant increased use of techniques not associated with EBTs for traumatic stress (cf. Brookman-Frazee, Haine, Baker-Ericzen, Zoffness, & Garland, 2010; Southam-Gerow, Chorpita, Miller, & Gleacher, 2008).

This study sought to evaluate the agreement between therapist report and coder observation of therapy practices. The study sampled session data from a community-based, randomized trial of treatment for youth ages 7 to 13. We used therapist report of session content and coverage gathered using formal Consultation Records and developed complimentary records for coders to use when watching or listening to therapy tape. We established initial reliability between coders and then conducted a random, stratified, and comprehensive sample of sessions across youth (N = 121), therapists (N = 57), conditions (MATCH and Standard Manuals), and study sites (Honolulu and Boston) to code and compare with therapist record reports. Intraclass correlation coefficients (ICCs) representing coder versus therapist agreement on manual content delivered ranged from .42 to 1.0 across conditions and problem areas. Analyses revealed marked variability in agreement regarding whether behavioral rehearsals took place (ICCs from -.01 to 1.0) but strong agreement on client comprehension of therapy content and homework assignments. Overall, the findings indicate that therapists can be accurate reporters of the therapeutic practices they deliver, although they may need more support in reporting subtle but valuable aspects of implementation such as types of behavioral rehearsals. Developing means to support accurate reporting is important to developing future clinical feedback methodology applicable to the implementation of evidence-based treatments in the real world.

OBJECTIVE This article reports outcomes from the Child STEPs randomized effectiveness trial conducted over a 2-year period to gauge the longer term impact of protocol design on the effectiveness of evidence-based treatment procedures. METHOD An ethnoracially diverse sample of 174 youths ages 7- 13 (N = 121 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, or disruptive behavior were treated by community therapists randomly assigned to 1 of 3 conditions: (a) standard, which involved the use of 1 or more of 3 manualized evidence-based treatments, (b) modular, which involved a single modular protocol (Modular Approach to Treatment of Children With Anxiety, Depression, or Conduct Problems; MATCH) having clinical procedures similar to the standard condition but flexibly selected and sequenced using a guiding clinical algorithm, and (c) usual care. RESULTS As measured with combined Child Behavior Checklist and Youth Self-Report Total Problems, Internalizing, and Externalizing scales, the rate of improvement for youths in the modular condition was significantly better than for those in usual care. On a measure of functional impairment (Brief Impairment Scale), no significant differences were found among the 3 conditions. Analysis of service utilization also showed no significant differences among conditions, with almost half of youths receiving some additional services in the 1st year after beginning treatment, and roughly one third of youths in the 2nd year. CONCLUSIONS Overall, these results extend prior findings, supporting incremental benefits of MATCH over usual care over a 2-year period.

This study compared consistencies and discrepancies in usual care with practices derived from the evidence-base (PDEB) for youth anxiety in a public mental health system. Youth-level factors (diagnosis, functional impairment) as predictors of the discrepancies were also examined. Psychosocial and service data from 2485 youth with an anxiety disorder and/or receiving services for an anxiety treatment target were extracted. Therapists (N = 616) identified the treatment targets and practices youth received. Although many PDEB for youth anxiety were used by therapists in this sample, Exposure was only used in 15% of cases. Practices not consistent with youth anxiety treatment were also reported and included: PDEB for other conditions, practices common to all therapies, and practices that are not consistent with evidence-based care. Age and diagnosis predicted the delivery of PDEB for youth anxiety. Usual care incorporated many components of evidence-based care but was more diffuse and less focused on well-supported practices.

How can we best facilitate the application of child/adolescent evidence-based treatments (EBTs) in community clinic settings? Many factors have been cited as potential barriers to successful implementation. For example, children treated in community settings tend to have higher comorbidity and greater ecological risks than children treated in university settings. At the provider level, attitudes about EBTs may influence whether or how a therapist chooses to implement the treatment. At the system level, financing constraints on dissemination tools, like training or availability of materials, may be obstacles. We review these factors using the Mental Health System Ecological (MHSE) model and offer recommendations for professional psychologists interested in overcoming these barriers. Our focus for this article is on the child, therapist, and system levels of the MHSE model.

Kazdin and Blase (2011) propose that traditional models of delivering therapy require more resources than are available to address the scope of mental illness. We argue that finding new platforms and avenues for our existing treatments is a good start but that it is not enough. We contend that the field also needs to develop formal strategies to reorganize its increasing abundance of knowledge to address the scarcity of resources for its application. If we can better utilize our existing knowledge, treatment delivery and service resource allocation can become more efficient and effective. If the field continues with its almost singular emphasis on knowledge proliferation (e.g., developing new treatments), as opposed to knowledge management (e.g., developing new ways to design, apply, and organize existing treatments), the problem outlined by Kazdin and Blase cannot be solved.

[Clin Psychol Sci Prac 18: 154–172, 2011] This updated review of evidence-based treatments follows the original review performed by the Hawaii Task Force. Over 750 treatment protocols from 435 studies were coded and rated on a 5-level strength of evidence system. Results showed large numbers of evidence-based treatments applicable to anxiety, attention, autism, depression, disruptive behavior, eating problems, substance use, and traumatic stress. Treatments were reviewed in terms of diversity of client characteristics, treatment settings and formats, therapist characteristics, and other variables potentially related to feasibility and generalizability. Overall, the literature has expanded considerably since the previous review, yielding a growing list of options and information available to guide decisions about treatment selection.

How can contextualized feedback on therapy practices and youth outcomes promote an evidence-basedculture for adolescent mental health? Relative to other quality improvement tools, feedback and progressmonitoring systems are generally underutilized. This article describes a feedback system collaborativelydeveloped by the Hawai‘i Department of Health Child and Adolescent Mental Health Division andprivate agency staff contracted to provide mental health services to youth. Feedback reports allowproviders to monitor progress of their youth clients, compare their progress with youth receiving similarservices, examine the extent they are using practices derived from evidence-based protocols, andcompare these practice profiles to what other youth are receiving. Providers gather to discuss reports,share success stories, and offer suggestions to improve practices and outcomes based on data from thereports. The provider feedback system in Hawai‘i has emphasized youth outcomes and has promoted an“evidence-based culture.” This article encourages direct providers and supervisors to consider how sucha system might fit in their current practice and whether contextualized feedback might be one way toenhance services and outcomes for youth with mental health needs.

[Clin Psychol Sci Prac 18: 24–35, 2011] This article provides a follow-up account of efforts associated with a statewide initiative established 10 years ago for identifying and implementing effective treatments for child and adolescent mental health concerns. The manner in which this initiative has evolved and endured within a complex public mental health service infrastructure may provide some important insights and even optimism about the application of science in public sector settings. This 10-year history illuminates the benefits and challenges of maintaining a community-based mechanism for the integration of science and practice. As reported here, such collaborative efforts can produce new ways to conceptualize scientific evidence, overcome interdisciplinary barriers, catalyze other progressive initiatives, and generate a guiding vision for public mental health for youth.

We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts.

Within a comprehensive mental health service array for youth, Intensive Home Based Services (IHBS) are designed to meet the needs of youth with significant emotional and behavioral problems in their home communities, avoiding the need for out-of-home services, particularly residential care. We examined youth receiving IHBS as their first service in the state of Hawaii system of care (N = 163) to determine how successful IHBS were in preventing the need for more restrictive services within 12 months of intake. Subsequently, we investigated characteristics that might be predictive of a youth’s need for service intensification within 12 months. Logistic regression analyses found that greater age, level of service need, and functional impairment at intake predicted use of more restrictive services within 12 months of intake, whereas gender, ethnicity, diagnosis, service intensity, and clinician credentials did not. Overall, our findings suggested that IHBS were reasonably successful in preventing residential placements, and provided some basis for determining characteristics of youth likely to require more restrictive placements within a one year period.

The present study examined youth characteristics that predict level of impairment at entry into a system of care and rate of improvement over the course of service provision. Youth characteristics studied included gender, age, specific diagnostic categories, and comorbidity. A total of 2,171 youth served in a state-wide public mental health system were included in the study. Hierarchical linear modeling was used to analyze longitudinal data derived from quarterly ratings of functional status. Gender had no relationship to initial level of impairment or rate of improvement. Older youth, those with disruptive behavior disorders, and those with more than one DSM diagnosis were more impaired at system entry. Those with attentional disorders began services less impaired. Older youth improved at faster rates. Youth with a disruptive behavior disorder diagnosis improved at slower rates. Neither comorbidity nor the presence of a mood or attentional disorder affected the rate of improvement. Both researchers and systems of care developers should consider these patterns in their future work.

This study applied the distillation and matching model to 322 randomized clinical trials for child mental health treatments. The model involved initial data reduction of 615 treatment protocol descriptions by means of a set of codes describing discrete clinical strategies, referred to as practice elements. Practice elements were then summarized in profiles, which were empirically matched to client factors (i.e., observed problem, age, gender, and ethnicity). Results of a profile similarity analysis demonstrated a branching of the literature into multiple problem areas, within which some age and ethnicity special cases emerged as higher order splits. This is the 1st study to aggregate evidence-based treatment protocols empirically according to their constituent treatment procedures, and the results point both to the overall organization of therapy procedures according to matching factors and to gaps in the current child and adolescent treatment literature.

We examined client outcomes from the implementation of Multisystemic Therapy (MST) in a statewide child and adolescent mental health system. Specifically, we examined (1) the validity of therapist-rated MST outcome measures by comparing them to ratings of functional impairment and level of service needs by CAMHD care coordinators, who provide case management and care coordination services, (2) potential client and service predictors of therapist-rated outcomes, and (3) improvement in youth functioning around the time of entry to and exit from MST compared with rates of improvement reported in randomized controlled trials (RCTs) by the developers of MST. Results suggested that therapist-rated MST outcomes were valid indicators of treatment success. Similar to other findings in the MST literature, few client or service characteristics predicted these outcomes. Finally, although MST entry–exit effect sizes were lower than the mean derived from RCTs published by the developers, they were within the 95% confidence interval. Together, these findings support the implementation of MST in complex systems of care with continued attention to quality assurance and ongoing use of data for evaluation.

Decades of research have examined the structure of self-consciousness in adults and its relationship to social anxiety. This study examined the structure of self-consciousness via the Self-Consciousness Scales (Fenigstein et al., J. Consult. Clin. Psychol. 43:522–527, 1975) in a school sample of 175 children and young adolescents (92 girls; mean age = 11.5). Confirmatory factor analysis best supported a five-factor solution (Internal State Awareness, Self-Reflectiveness, Appearance Consciousness, Style Consciousness and Social Anxiety). Although some factor based subscales evidenced low internal consistencies, convergent and discriminant correlations with self-report measures of social phobia, negative affect, and positive affect as well as parent-report measures of internalizing and externalizing problems provided additional support for the five-factor model. Future studies should further examine the multidimensional nature as well as the developmental course of self-consciousness and its relation to social anxiety longitudinally.

This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in com- munity services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured deci- sion making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support deci- sions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underly- ing this system—mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels—can be implemented to support clinical practice in a wide variety of settings.

Science has fostered renewed optimism in mental health practice over the last decade through advances in the development of treatment supported by research (Kazdin and Weisz, 2003; Task Force on Promotion and Dissemination of Psychological Procedures, 1995; Wilson, 1995). The challenge that continues to confront both the scientific and applied domains of psychology and psychiatry is the widespread promotion and implementation of empirically supported treatments in general, and in children_s mental health in particular (Barlow, 2000; Chorpita et al., 2002; Schoenwald and Hoagwood, 2001; Weisz et al., 1995). With more than 500 documented treatments available for children and adolescents (Kazdin, 2000), how do practicing clinicians begin to identify the appropriate evidence-based interventions for their clients? On the one hand, it would appear that practitioners could consult the literature to learn more about efficacious interventions for particular problem areas. On the other hand, the increasing proliferation of guidelines, lists, and definitions that has followed has been rather complex (e.g., Chorpita et al., 2002; Lonigan et al., 1998; Schinke et al., 2002; Weisz, 2003), and in some ways has paradoxically increased the complexity of identifying Bbest candidate[ interventions for treating children_s disorders. Contributing to the complexity of identifying evidence-based interventions is ambiguity surrounding the meaning of the term Bevidence-based.[ Traditionally, albeit a recent tradition, the term has denoted specific treatment protocols with a particular degree and type of empirical support (e.g., Chambless and Hollon, 1998). Thus, the Bmanualization[ of interventions (e.g., Coping Cat, Kendall, 1990; Defiant Children, Barkley, 1997) has lent itself to a method of defining evidence-based treatments. At this manual level of analysis, practitioners may choose from a variety of specific treatment programs that have demonstrated their efficacy in research trials. However, evidencebased, manualized treatments often have overlapping strategies, and it is difficult for practitioners to determine the relative appropriateness of one given treatment manual over another for particular clients and situations (Kazdin et al., 1990).

We examined whether clinical progress ratings on the Monthly Treatment and Progress Summary form (MTPS), an idiographic treatment progress measure, were meaningfully related to changes measured by two separate standardized instruments; the Child and Adolescent Functional Assessment Scale (CAFAS) and the Child and Adolescent Level of Care Utilization System (CALOCUS). Validity coefficients were examined at intake and three-, six-, and nine-month follow-up periods. Samples were selected for each measure and follow-up period from the population of youth receiving services through the Hawaii Child and Adolescent Mental Health Division’s (CAMHD) system of care. Significant youth improvement was evident on all three measures across all follow-up intervals. The type of changes measured by the MTPS and CAFAS were more alike over longer follow-up intervals than changes measured by the CALOCUS. The MTPS captures distinct aspects of client change that overlaps somewhat with CAFAS and CALOCUS measures. The MTPS is a brief client-tailored measure that seems to provide valid, sensitive, and nonredundant client specific treatment outcome information that can be collected on a frequent basis within a complex system of care.

We select and comment on concepts and examples from the target articles in this special issue on measurement feedback systems, placing them in the context of some of our own insights and ideas about measurement feedback systems, and where those systems lie at the intersection of technology and decision making. We contend that, connected to the many implementation challenges relevant to many new technologies, there are fundamental design challenges that await a more elaborate specification of the clinical information and decision models that underlie these systems. Candidate features of such models are discussed, which include referencing multiple evidence bases, facilitating observed and expected value comparisons, fostering collaboration, and allowing translation across multiple ontological systems. We call for a new metaphor for these technologies that goes beyond measurement feedback and encourages a deeper consideration of the increasingly complex clinical decision models needed to manage the uncertainty of delivering clinical care.

Objective This study empirically examined options for building an evidence-informed service array, comparing strategies to maximize the application of evidence-based treatment literature in a clinical service system. The overall goal was to determine the smallest set of treatments that could serve the largest percentage of clients. Solutions to this problem differ depending on how one defines "treatment." Method Treatments were conceptualized as (a) programs (integrated treatments produced by specific research laboratories or investigators), and (b) collections of their constituent common procedures, referred to as practice elements. Programs listed by 2 separate government-sanctioned registries were selected to illustrate the effects of "program" conceptualizations, and all available clinical trials testing the programs were analyzed. Practice elements were identified from these same studies and from studies of other treatments that met a standard of evidence but had not been organized into programs on these lists. Relevance mapping methodology was used to identify optimal sets of programs and practice elements. Results Among a large, diverse clinical population, results identified 11%-22% of youths for whom practice elements provide an evidence-informed treatment option whereas no programs meeting the standard of evidence were available on the registries. Results for the practice elements were able to be matched by a hybrid combination: "best" programs, which were then extended by practice elements. Conclusions These results demonstrated that there are multiple ways to conceptualize treatments when planning a service array, and these options have significant implications regarding who can be served by treatments supported by evidence.

Validity and parent-child agreement of the Social Phobia and Anxiety Inventory for Children-Parent Report (SPAI-C-P) were examined in a racially diverse sample of 158 students in Grades 5 through 8 (87 girls; ages 10 to 14; M = 11.53) and their caregivers. Children completed the Social Phobia and Anxiety Inventory for Children (SPAI-C), and caregivers completed the SPAI-C-P and the Child Behavior Checklist (CBCL). The SPAI-C-P demonstrated good internal consistency and was significantly correlated with child self-reported social anxiety. Confirmatory factor analysis supported a 3-factor model over a 5-factor model, and concurrent validity was evidenced. Implications and directions for future research are discussed.

Diversity is a hallmark of behavioral health care systems. Many different people, with many different backgrounds and interests, are involved in many different activities through many different human organizations. Given this diversity, it is not surprising that multiple conflicting views emerge about how limited resources should be distributed, who should be served, and what services should be provided. Among this diversity, one common rallying point is the notion that when services are provided, better quality of life should result. During the past 10 years, public mental health services for children and youths in Hawaii experienced a major system restructuring. The five current goals of the Department of Health Child and Adolescent Mental Health Division (CAMHD) strategic plan are shared ownership, accountable business practices, system of care principles, evidence-based practices, and performance evaluation (Child and Adolescent Mental Health Division, 2003). Before the system reform, child and adolescent mental health services in Hawaii were generally delivered through a direct service model by small teams at regional guidance centers. At present, CAMHD orchestrates a public-private collaboration with eight regional public family guidance branches providing care coordination and administrative services and approximately 35 contracted private provider agencies delivering the majority of direct care. The comprehensive system of care framework, which was locally demonstrated through the federally funded Ohana project, is the statewide model for delivery of intensive mental health services, except on the island of Kauai, where an integrated schoolbased program is used. Elsewhere, educationally supportive, less intensive (e.g., day treatment), and outpatient services are arranged through the schoolbased behavioral health program of the Department of Education. For the Medicaid-eligible population, less intensive and outpatient services are provided through the state-contracted health plans. This latest reorganization was largely completed in 2002. A major evidence-based services initiative was implemented following the initial development of the system of care (Table 1; see Chorpita and Donkervoet, 2005). Approximately 5 years into the system of care reform, an evaluation identified marked increases in the number of youths accessing services, as well as the amount, types, and total cost of mental health services. In addition, qualitative analyses identified weaknesses in the provider array in the form of undesirable use of restrictive levels of care (e.g., serving youths with conduct disorders in hospital settings) and use of therapeutic approaches with uncertain efficacy. It was unclear whether this expanded investment was associated with better child and family functioning. To move forward, system leaders initiated quarterly quantitative child status assessments and explored large-scale dissemination of evidence-based services as an initiative Accepted January 5, 2006. Drs. Daleiden and Arensdorf, Ms. Brogan, and Ms. Donkervoet are with the Hawaii Department of Health Child and Adolescent Mental Health Division, Honolulu; and Dr. Chorpita is with the Department of Psychology, University of Hawaii at Manoa, Honolulu. This project was funded with state general funds through the Hawaii Department of Health Child and Adolescent Mental Health Division. The findings described in this column were produced through the collaborative efforts of countless youths, families, and professionals who contribute to the Hawaii system of care for child and adolescent mental health. Correspondence to Dr. Eric Daleiden, 3627 Kilauea Avenue, Room 101, Honolulu, HI 96816; e-mail: eldaleid@camhmis.health.state.hi.us. 0890-8567/06/4506-0749 2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000215154.07142.63 E V I D E N C E B A S E D P R A C T I C E Assistant Editor: John D. Hamilton, M.D., M.Sc.

This study examined the degree to which a literature review of evidence-based services identified services appropriate for the actual problems of youth involved in intensive public mental health services. The diagnostic profiles and specific intervention targets reported by treatment providers were coded to determine whether a relevant empirically supported treatment was identified in the literature by the Hawaii Evidence-Based Services Committee for each problem. Of the 2,197 youth with diagnostic information available, 721 youth (33%) had a pure diagnosis for which an evidence-based service was identified in the literature, and 1,953 youth (89%) had a primary diagnosis with a relevant evidence-based service. Of the 1,220 youth with treatment target information, 1,094 (90%) had 1 or more problem areas targeted for intervention with an identified evidence-based service; thus, the vast majority of youth receiving intensive public mental services experienced a mental health difficulty for which an evidence-based service was identified through a review of the empirical literature. Nevertheless, many youth had additional problems for which evidence-based services have not yet been identified through research.