Caregiver Engagement in Outpatient Treatment for Adolescents in Community Settings: Construct and Predictive Validity of Family Therapy Techniques

Caregiver engagement and participation in community-based outpatient treatment services for adolescents is generally poor, which is problematic given the integral role of caregivers prescribed by evidence-based treatments across orientations. The current study explores the psychometric and predictive properties of a set of caregiver engagement techniques distilled from family therapy, used by community clinicians in routine care. It highlights relational engagement interventions and adds to growing work distilling core elements of family therapy. The study examined caregiver engagement techniques observed in 320 recorded sessions and outcome data from 152 cases treated by 45 therapists participating in one of three randomized trials investigating delivery of family therapy for adolescent behavior problems in community settings. Construct and predictive validity of caregiver engagement coding items were analyzed to understand the degree to which they cohered as a single factor and predicted outcomes in predictable ways. Results demonstrated item reliability and construct validity of a Caregiver Engagement Techniques factor. Greater use of these techniques was associated with decreased adolescent substance use. Unexpected results suggested greater use of techniques was associated with worsening internalizing symptoms and family cohesion per youth-report only. Post-hoc analyses revealed additional complexities in the association between engagement techniques and outcomes. Caregiver engagement practices tested in the current study represent a unified treatment factor that may contribute to positive therapeutic outcomes for adolescents in some clinical domains. Further research is needed to understand predictive effects.

Therapist Self-Report of Fidelity to Core Elements of Family Therapy for Adolescent Behavior Problems: Psychometrics of a Pragmatic Quality Indicator Tool

Therapist-report measures of evidence-based interventions have enormous potential utility as quality indicators in routine care; yet, few such tools have shown strong psychometric properties. This study describes reliability and validity characteristics of a therapist-report measure of family therapy techniques for treating adolescent conduct and substance use problems: Inventory of Therapy Techniques for Core Elements of Family Therapy (ITT-CEFT). Study participants included 31 staff therapists treating 68 adolescent clients in eight community-based mental health and substance use clinics. Therapists submitted ITT-CEFT checklists and companion audio recordings for 189 sessions. The ITT-CEFT contains 13 techniques identified as core elements of three manualized family therapy models that are empirically supported for the target group. Therapists also reported on their use of three motivational interventions, and independent observers coded the submitted recordings. ITT-CEFT factor validity was shown via confirmatory factor analyses of the tool's theoretical structure. Derived modules were: Family Engagement (four items; Cronbach's α = .72); Relational Orientation (five items; α = .74); and Interactional Change (four items; α = .66). Concurrent validity analyses showed fair-to-excellent therapist reliability compared to observer ratings (ICCs range .64-.75); they showed moderate therapist accuracy compared to observer mean scores, reflecting a tendency to overestimate delivery of the techniques. Discriminant validity analyses showed tool differentiation from motivational interventions. Results offer provisional evidence for the feasibility of using the therapist-report ITT-CEFT to anchor quality procedures for family therapy interventions in real-world settings.Trial Registration: The parent clinical trial is registered at www.ClinicalTrials.gov , ID: NCT03342872 (registration date: 11.10.17).

Benchmarking Family Therapy for Adolescent Behavior Problems in Usual Care: Fidelity, Outcomes, and Therapist Performance Differences

This study evaluated whether community therapists delivering family therapy for adolescent behavior problems in usual care achieved performance benchmarks established in controlled trials for treatment fidelity and outcomes, with particular focus on individual differences in therapist performance. The study contained N = 38 adolescents (50 % male; mean age 15 years) whose self-reported race/ethnicity was Hispanic (74 %), African American (11 %), multiracial (11 %), and other (4 %). Clients were treated by 13 therapists in one community mental health clinic that delivered family therapy as the routine standard of care. Therapists provided self-report data on adherence to core family therapy techniques; these scores were inflation-adjusted based on concordance with observer reports. Results showed that community therapists surpassed the fidelity benchmark for core family therapy techniques established by research therapists during a controlled trial. Regarding change in client functioning at 6-month follow-up, community therapists were equivalent to the benchmark for internalizing symptoms and superior for externalizing symptoms and delinquent acts. Community therapists also demonstrated a high degree of performance uniformity: Each one approximated the fidelity benchmark, and only two produced relatively weak outcomes on any of the client change indicators. Caveats for interpreting therapist performance data, given the small sample size, are described. Recommendations are made for developing therapist-report fidelity measures and utilizing statistical process control methods to diagnose therapist differences and enhance quality assurance procedures.