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.

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7-17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel "alliance rupture" model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

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Objective-To identify trajectories of behavioral adjustment from ages 6 to 14 for youth placed in early foster care, and to examine links between trajectories and early cognitive ability and social competence; caregiver stability; and frequency, timing, and type of maltreatment. Method-Participants were 279 youth from the Southwest site of the Consortium for Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). All youth had spent at least 5 months in out-of-home care prior to age 4 due to substantiated reports of maltreatment. Behavioral adjustment was assessed using caregiver reports on the Child Behavior Checklist at ages 6, 8, 10, 12, and 14. Cognitive ability and social competence were assessed at age 6. Caregiver stability was recorded every two years from age 6 to 14 and summed. Child protective services (CPS) maltreatment reports were coded for type and frequency. Results-Growth mixture modeling identified 3 internalizing trajectories: stable adjustment (66.7%), mixed/decreasing adjustment (25.4%), and increasing adjustment (7.9%). Four externalizing trajectories were identified: stable adjustment (46.6%), mixed adjustment (28.7%), increasing adjustment (8.2%), and stable maladjustment (16.5%). Trajectories of stable or increasing adjustment were predicted by social competence, cognitive ability, placement stability, and low frequency of physical abuse from ages 6 to 14. Conclusions-Many youth who have spent time in early out-of-home care evidence stable, long-term positive behavioral adjustment. Trajectories reflecting more positive adjustment are associated with early child cognitive ability and social competence, long-term caregiver stability, and low frequency of physical abuse in middle childhood and adolescence. Keywords maltreatment; child welfare; growth mixture modeling; behavioral adjustment Nearly 50% of youth placed in out-of-home care by child protective services experience behavior problems in the clinical range, according to the results of cross-sectional research.