Group CBT for Externalizing Disorders in Urban Schools: Effect of Training Strategy on Treatment Fidelity and Child Outcomes

Abstract

Public schools are an ideal setting for the delivery of mental health services to children. Unfortunately, services provided in schools, and more so in urban schools, have been found to lead to little or no significant clinical improvements. Studies with urban school children seldom report on the effects of clinician training on treatment fidelity and child outcomes. This study examines the differential effects of two levels of school-based counselor training: training workshop with basic consultation (C) vs. training workshop plus enhanced consultation (C+) on treatment fidelity and child outcomes. Fourteen school staff members (counselors) were randomly assigned to C or C+. Counselors implemented a group cognitive behavioral therapy protocol (Coping Power Program, CPP) for children with or at risk for externalizing behavior disorders. Independent coders coded each CPP session for content and process fidelity. Changes in outcomes from pre to post were assessed via a parent psychiatric interview and interviewer-rated severity of illness and global impairment. Counselors in C+ delivered CPP with significantly higher levels of content and process fidelity compared to counselors in C. Both C and C+ resulted in significant improvement in interviewer-rated impairment; the conditions did not differ from each other with regard to impairment. Groups did not differ with regard to pre- to- posttreatment changes in diagnostic severity level. School-based behavioral health staff in urban schools are able to implement interventions with fidelity and clinical effectiveness when provided with ongoing consultation. Enhanced consultation resulted in higher fidelity. Enhanced consultation did not result in better student outcomes compared to basic consultation. Implications for resource allocation decisions with staff training in EBP are discussed.

Implementation Support Skills: Findings From a Systematic Integrative Review

“…When ISPs are providing consultation/facilitation , five common components emerged across studies: (1) identifying the support needs of those involved in the consultation/facilitation efforts, for example, through formalized, periodic needs assessments (Duffy et al, 2012), structured interviews (Bice-Urbach & Kratochwill, 2016), or by explicitly inviting stakeholders to articulate their support needs in each session (Akin, 2016; Chilenski et al, 2016); (2) educating and professionally supporting these stakeholders, for example, through processes such as learning from others (Akin, 2016), role-plays (Barac et al, 2018), didactic teaching (Beidas et al, 2013; Chaffin et al, 2016), answering questions (Chilenski et al, 2016; Hurtubise et al, 2016; Kelly et al, 2000), or offering advice (Rosen et al, 2012); (3) monitoring the progress and/or performance of stakeholders, for example, by measuring fidelity (Bice-Urbach & Kratochwill, 2016; Caron & Dozier, 2019; Eiraldi et al, 2018; Murray et al, 2018), program outcomes (Funderburk et al, 2015; Olson et al, 2018), or progress toward other implementation or service goals (Chilenski et al, 2016; Holtrop et al, 2008; Preast & Burns, 2018); (4) identifying implementation barriers and problems faced as part of the change efforts, typically related to learning a new practice (Dusenbury et al, 2010; Eiraldi et al, 2018; Kauth et al, 2010; Nadeem, Gleacher, Pimentel, et al, 2013) and/or enabling its implementation within a particular local context (Rosella et al, 2018; Saldana & Chamberlain, 2012; Tierney et al, 2014); and (5) identifying potential solutions to these problems, including next steps to initiate these. This final step was at times characterized as “troubleshooting” (Chaffin et al, 2016; Hodge et al, 2017; Meropol et al, 2014) signaling a more urgent and ad hoc type of character that this strategy could take.…”

“…Studies reflected that consultation/facilitation was provided to individuals (Bradshaw et al, 2012; Rosen et al, 2012) as well as groups of stakeholders (Kousgaard & Thorsen, 2012; Murray et al, 2018) and occurred either in-person (Anyon et al, 2016; Dobbins et al, 2018; Eiraldi et al, 2018), or remotely (C. H. Brown et al, 2014; Gustafson et al, 2013; Kauth et al, 2010).…”

“…The use of audit and feedback involved multiple activities for the ISP, including sourcing relevant administrative or statistical data or self-collecting such data (Burns et al, 2008; Dickinson et al, 2014; Jacobson et al, 2019; Meropol et al, 2014), summarizing these data in relevant and operational ways (Calo et al, 2018; Chaple & Sacks, 2016; Chinman et al, 2018; Mold et al, 2008), presenting them for stakeholders (Holtrop et al, 2008; Jacobson et al, 2019), and promoting a discussion of findings enabling stakeholders to set priorities for improvements (McCullough et al, 2017; Preast & Burns, 2018). Multiple studies also included descriptions of ISPs tracking and assessing fidelity data to better understand whether interventions were implemented as intended by their developers (Brunette et al, 2008; Chinman et al, 2018; Eiraldi et al, 2018; Gunderson et al, 2018; Kirchner et al, 2014), highlighting that evaluative functions were included in implementation support.…”

Examining the Impact of Treatment Fidelity on Client Outcomes in a Statewide Implementation of Parent-Child Interaction Therapy

“…The extant literature does not fully resolve this debate. Although increases in treatment fidelity do not consistently correspond with improvements in client outcome across all treatment modalities (Webb, DeRubeis, & Barber, 2010;Eiraldi et al, 2018), treatment fidelity has been associated with several factors that are related to client outcome, such as clinician attitudes, clinician motivation, and client problem severity (Perepletchikova & Kazdin, 2005). Other research has shown that moderate levels of treatment adherence are more predictive of treatment outcome than high levels of treatment adherence, suggesting a curvilinear fidelity-outcome relation (Barber et al, 2006).…”

“…Previous research has not sufficiently addressed the relationship between treatment adherence, clinician competence, and family treatment outcomes across various types of psychotherapy (Barber et al, 2006;Breitenstein et al, 2010b;Eiraldi et al, 2018). This is especially true in the PCIT literature.…”