This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month followup. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.Keywords treatment adherence; therapist competence; adolescent substance use; cognitive-behavioral therapy; multidimensional family therapy Rigorous fidelity monitoring and evaluation are required elements of efficacy research on manual-based behavioral interventions (Carroll, Kadden, Donovan, Zweben, & Rounsaville, 1994), and fidelity research is rapidly becoming a centerpiece of treatment dissemination as well. Some evidence has indicated that strong fidelity to empirically based interventions may be essential for producing treatment effects in real world settings. For example, Henggeler and colleagues (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997;Henggeler, Pickrel, & Brondino, 1999) found that fidelity to multisystemic therapy for delinquent adolescents was poor when community therapists implemented the model without ongoing supervision from model experts; moreover, poor fidelity was linked to worse outcomes compared with results NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript from efficacy studies. Interestingly, Morgenstern, Morgan, McCrady, Keller, and Carroll (2001) showed that whereas community practitioners intensively trained in cognitivebehavioral therapy for adult substance abuse could reach fidelity and outcome benchmarks set by research therapists, control group practitioners with no additional training reached the same outcome benchmarks. As dissemination research continues to mature, it seems certain that fidelity issues will remain a priority for treatment developers, program administrators, and policymakers.Research on the link between fidelity and outcome i...

This study introduces an observational measure of fidelity in evidence-based practices for adolescent substance abuse treatment. The Therapist Behavior Rating Scale-Competence (TBRS-C) measures adherence and competence in individual cognitive-behavioral therapy and multidimensional family therapy for adolescent substance abuse. The TBRS-C assesses fidelity to the core therapeutic goals of each approach and also contains global ratings of therapist competence. Study participants were 136 clinically referred adolescents and their families observed in 437 treatment sessions. The TBRS-C demonstrated strong interrater reliability for goal-specific ratings of treatment adherence, and modest reliability for goal-specific and global ratings of therapist competence, evidence of construct validity, and discriminant validity with an observational measure of therapeutic alliance. The utility of the TBRS-C for evaluating treatment fidelity in field settings is discussed.

While adults with mental retardation as a group showed consent deficits, many attained consent capacity scores comparable to those of comparison subjects. Investigators should consider individual differences and a consent format suited to deficits in language, memory, and attention before restricting consent opportunities for persons with mental retardation.

Adolescent males who have sex with males (AMSM) are at increased risk of contracting HIV/AIDS and other sexually transmitted infections (STIs). Healthcare providers are a critical source of HIV/STI prevention, yet little is known about AMSM patient-provider sexual health communications and services. To explore this issue, we surveyed a national sample of 198 AMSM 14 – 17 years. Four online psychometrically validated scales indicated over half the youth avoided communicating their sexual orientation and sexual health concerns to providers due to fear of heterosexist bias, concern their sexual health information would be disclosed to parents, and a general belief that sexual minority youth did not receive equitable treatment in health care settings. Youth who reported their physicians had initiated discussion about their sexual orientation were significantly more likely to have received HIV/STI preventive services and testing. Discussion includes the need for medical training that meets the unique sexual health needs of AMSM.

Transgender youth may not discuss their GSM identity or sexual health with PCPs because they anticipate GSM stigma and fear being "outed" to parents. PCPs should receive transgender-inclusive training to adequately address youths' sexual health needs and privacy concerns.