4503
l_8986
journal_a_article_5.pdf
Dissemination and Implementation of Evidence Based Treatments for Youth: Challenges and Recommendations
Michael A. Southam-Gerow and Adriana Rodrı́guez Virginia Commonwealth University
Bruce F. Chorpita University of California, Los Angeles
Eric L. Daleiden PracticeWise, LLC, Satellite Beach, FL
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 implemen- tation. 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 recom- mendations 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.
Keywords: evidence-based practice, dissemination and implementation, children’s mental health treat- ment, treatment adaptation
Given the alarming prevalence rates of psychopathology in children (e.g., Hoagwood & Olin, 2002), concerning numbers of children who do not receive adequate treatments (e.g., Tang, Hill,
& Boudreau, 2008), and links between childhood and adolescent disorders to adulthood disorders (e.g., Copeland, Shanahan, Costello, & Angold, 2009), there have been extensive efforts to develop and test mental health treatments. These efforts have led to the development of a multitude of what have been called evidence-based treatments (EBTs) for various childhood disorders (e.g., Chorpita et al., 2011). The development and identification of EBTs has been important for the field; however, researchers have recently highlighted some shortcomings of the approach (e.g., Beidas & Kendall, 2010; Schoenwald & Hoagwood, 2001). Most important, evidence to date suggests mixed findings when EBTs are tested in diverse community settings. Some studies have found strong effects for EBTs (e.g., Swenson, Schaeffer, Henggeler, Faldowski, & Mayhew, 2010; Weisz et al., 2012) whereas others have found that EBTs have failed to perform better than usual care (e.g., Clarke et al., 2005; Southam-Gerow et al., 2010).
Treatment programs tend to be developed for a specific child disorder, a focus with significant limitations. Because multiple factors beyond the child’s disorder influence how potent a treat- ment will be, Southam-Gerow, Ringeisen, and Sherrill (2006; cf. Schoenwald & Hoagwood, 2001) outlined a model, the Mental Health Systems Ecological (MHSE) model (see Figure 1), depict- ing the importance of (a) child and family factors, (b) therapist factors, (c) organization factors, and (d) service system factors. Similar to other approaches (e.g., Damschroder & Hagedorn, 2011; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Proctor et al., 2009), the MHSE model emphasizes the importance of the entire ecology in the adaptation of treatments for dissemination and implementation research. Specifically, the MHSE model pos- its that a consideration of broader factors (i.e., beyond child symptoms) may lead to more successful dissemination of treat- ments—and more successful outcomes. For example, child char-
This article was published Online First June 25, 2012. MICHAEL A. SOUTHAM-GEROW received his PhD in clinical psychology from Temple University. He is an associate professor and the graduate director in the Department of Psychology at Virginia Commonwealth University. His areas of research and practice include training in and study of evidence-based practices for children and adolescents, dissemination and implementation, treatment integrity, and emotion regulation. ADRIANA RODRÍGUEZ received her B.A. in psychology from the University of California, Berkeley. She is a graduate student in the Department of Psychol- ogy at Virginia Commonwealth University. Her areas of research interest include implementation and dissemination and cultural and linguistic adapta- tions of assessments for minority populations in real-world clinic settings. BRUCE F. CHORPITA received his PhD in clinical psychology from the State University of New York at Albany. He is currently a professor in the Department of Psychology at the University of California, Los Angeles. His research is aimed at improving the effectiveness of mental health services delivered to children, through innovation in mental health treat- ment design, clinical decision-making and information-delivery models, and mental health system architecture and processes. ERIC L. DALEIDEN received his PhD in psychology from The Ohio State University. He is the Chief Operating Officer of PracticeWise, LLC, a partnership that provides information resources, training, and consultation services related to evidence-based practices for youth mental health. His areas of research and practice include developmental psychopathology, evidence-based practice, and health system evaluation. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Mi- chael A. Southam-Gerow, VA Commonwealth University, Department of Psychology, 806 W. Franklin St. Box 842018, Richmond, VA 23284-2018. E-mail: [email protected]
Professional Psychology: Research and Practice © 2012 American Psychological Association 2012, Vol. 43, No. 5, 527–534 0735-7028/12/$12.00 DOI: 10.1037/a0029101
527
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
acteristics beyond symptoms and diagnoses (e.g., Southam-Gerow, Chorpita, Miller, & Gleacher, 2008), therapist attitudes toward EBTs (e.g., Aarons, 2004), the culture and climate of a service organization (Glisson et al., 2008), and system-wide policies (e.g., Schoenwald & Hoagwood, 2001) all have a potential influence on how well a treatment will work.
These ecological factors become more salient as EBTs move from the lab into the community, making them particularly rele- vant for professional psychologists. Due to their unique skill set grounded in science and practice, professional psychologists are often in roles of providing services as well as managing, directing, and/or supervising the dissemination of evidence-based treatments (e.g., Chorpita, 2003). Thus, in this article, we outline some implications of the MHSE model with regard to dissemination and implementation of EBTs in community settings, with an emphasis on the roles that professional psychologists can play in the effort. Specifically, we provide three suggested ways to overcome obsta- cles posed at three of the four levels of the MHSE model, empha- sizing those challenges most relevant to professional psycholo- gists:1 (a) client/family diversity, (b) therapist training, and (c) systems-level factors.
Child/Family Factors
The MHSE model suggests, and empirical evidence supports (e.g., Baker-Ericzén, Hurlburt, Brookman-Frazee, Jenkins, & Hough, 2010; Ehrenreich-May et al., 2011), the idea that children seen in many community service settings are notably different from children seen in many research clinics, particularly with regard to (a) child comorbidity and (b) child/family diversity (e.g., cultural, socioeconomic status). Although it is not clear from the evidence that these factors will reduce the efficacy of EBTs when disseminated to various service settings, some consideration of how to handle such challenges is warranted. We focus our discus- sion here on child/family cultural diversity. Important work related to child comorbidity is discussed elsewhere (e.g., Chorpita & Daleiden, 2010; Chu, Merson, Zandberg, & Margaret, 2012; Eh- renreich, Goldstein, Wright, & Barlow, 2009).
One possible concern with the applicability of EBTs across service settings is that most have been tested with primarily Caucasian and middle-class (or higher) families, thus raising the question as to whether or not these treatments will work for other populations without modifications (e.g., Huey & Polo, 2008; Mak, Law, Alvidrez, & Pérez-Stable, 2007). Both child/family minority status and low family income have been associated with premature termination of treatment or attenuation of treatment effects (e.g., Curry et al., 2006; Miller, Southam-Gerow, & Allin, 2008) and with lower levels of child/family engagement in treatment (e.g., Hoagwood et al., 2010; McKay et al., 2004). Thus, therapists working in settings with many diverse children may be hesitant to apply and/or support adoption of EBTs because these approaches have rarely been tested with the children most likely to pose engagement challenges.
Second, even if such engagement challenges were overcome, therapists may question the potency of EBTs across ethnic groups (and across the spectrum of income levels), raising the question of whether or not adaptations to the EBTs are needed. In this section, we focus on the issues of possible adaptations related to child ethnicity. We refer the reader to other sources for a discussion of engagement (e.g., Hoagwood et al., 2010; McKay et al., 2004; Nock & Kazdin, 2001) and adaptations related to family income (e.g., Atkins et al., 2006; Cappella, Frazier, Atkins, Schoenwald, & Glisson, 2008; Lim, Follansbee-Junger, Crawford, & Janicke, 2011).
A relevant question for a therapist to ask about EBTs would be, what (if any) adaptations might be needed when using an EBT with ethnically diverse children? In a meta-analysis of child treat- ment outcomes studies focused on ethnic minority children, Huey and Polo (2008) offered a few tentative conclusions, tentative because ethnic minorities are underrepresented in the literature. First, they noted that EBTs have been identified for ethnic minority children across a number of problem areas and ethnic groups. However, they noted that no treatment has yet met the well- established category as defined by Chambless et al. (1996). Fur- ther, they concluded that the evidence was inadequate to demon- strate (a) whether or not EBTs have equivalent, superior, or inferior effects with minority children or (b) whether or not culture-responsive treatments produce better effects. Accordingly, some consideration to cultural adaptations to EBTs is warranted (e.g., Cunningham, Foster, & Henggeler, 2002; Martinez & Eddy, 2005). Although maximizing therapist-client cultural match (see Sue, 1998 for discussion) and adjusting treatments to correspond to cultural beliefs and preferences of diverse families (e.g., Dwight- Johnson, Sherbourne, Liao, & Wells, 2000; Yeh et al., 2005) have been suggested in the literature, we focus here on models for culturally adapting EBTs.
Bernal, Bonilla, and Bellido (1995) outlined several dimensions important for culture-relevant adaptations, including language, content (i.e., cultural knowledge), concepts (i.e., the extent to which concepts in the treatment are consonant with those of the child’s culture), and goals, an approach that has been successfully applied (e.g., McCabe & Yeh, 2009; Rosselló, Bernal, & Rivera- Medina, 2008). Domenech-Rodrı́guez and Wieling (2005) ex-
1 Note that we do not discuss factors at the organizational level of the model. We refer the reader to other sources for discussion of this important level (Fixsen et al., 2005; Glisson & Schoenwald, 2005).
Figure 1. Mental Health Systems Ecological model.
528 SOUTHAM-GEROW, RODRÍGUEZ, CHORPITA, AND DALEIDEN
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
panded on the Bernal et al. (1995) approach by emphasizing the inclusion of science in the process and integrating stakeholders into the adaptation process. Efforts to apply this model have also found empirical success (e.g., Domenech-Rodrı́guez, Baumann, & Schwartz, 2011; Nicolas, Arntz, Hirsch, & Schmiedigen, 2009).
Taking a somewhat different tack, Hwang (2006, 2009) outlined two contrasting models for cultural adaptation, the Psychotherapy Adaptation and Modification Framework (PAMF) and the Forma- tive Method for Adapting Psychotherapy (FMAP) model. The PAMF model is a top-down approach (Hwang, 2006), wherein research and other data inform a therapist’s approach to cultural adaptation. Some empirical data support the PAMF approach (Wood, Chiu, Hwang, Jacobs, & Ifekwunigwe, 2008). The FMAP is a “community-based, bottom-up approach” (Hwang, 2009, p. 370) wherein community stakeholders are involved in adaptation in a phasic manner (cf. Domenech-Rodrı́guez & Wieling, 2005). Research using the FMAP is ongoing (Hwang, 2009).
The four models have more in common than not (see Bernal, Jiménez-Chafey, & Domenech-Rodrı́guez, 2009) and all suggest the importance of considering how culture and ethnicity may influence how a therapist delivers a psychological treatment. How- ever, the question that started this section remains largely unan- swered: What, if any, adaptations might a therapist need to make to EBTs when working with ethnically diverse children? All four models provide the how for adaptation (e.g., adapting language and content to be culturally consonant, seeking stakeholder input about possible adaptations). However, they offer less guidance on the question whether to adapt. To address this gap, Lau (2006) pro- posed a framework for what she calls “selective adaptation” wherein cultural adaptation may be justified when evidence sug- gests either that (a) differences are present among cultural groups related to important risk or protective factors or (b) outcomes for a treatment differ by cultural group.
Thus, practical guidance for therapists aiming to adapt EBTs for use with diverse clients would include: (a) consideration of whether the literature indicates differential outcomes for youth in the cultural group of their clients, (b) acquisition of knowledge about how risk and protective factors differ across cultural groups, and (c) for situations in which adaptation seems appropriate, understanding of a cultural adaptation model (e.g., Bernal et al., 2009; Domenech-Rodrı́guez et al., 2011 Hwang, 2009) to help guide adaptation to content (e.g., language, use of concepts) or process (e.g., involvement of family members) in treatment.
However, there are some ethnic/cultural group and problem area combinations (e.g., Native American children with anxiety disor- ders) for which the evidence may not be adequate to guide clinical decision-making. How then to proceed? A specific example might help. Take a 10-year-old male Latino child client who is referred to the clinic for attentional problems. A search of the evidence reveals only two RCTs for attentional problems have been con- ducted that included Latino clients (Chorpita et al., 2011). When not constraining the search by ethnicity (i.e., any ethnic group), the number of studies increases to 26 (Chorpita et al., 2011).
In this situation, a therapist has at least three options. First, she could choose to rely on the larger evidence base, arguably a safer option because of the larger evidence base for the problem type, age, and gender of the child, albeit without much data that may apply to the child’s ethnic group. Second, the therapist could rely on the smaller evidence base that matched problem type, age,
gender, and ethnicity, arguably the more culturally relevant option. A third option, akin to the Lau (2006) approach, might be to make cultural adaptations, based on local knowledge (i.e., stakeholder involvement), to a treatment selected using the one of the first two options. Although any of the three options are defensible, tracking outcomes closely would be an important step to ensure the adapted approach is working.
In short, given the increasingly diverse population of the United States (U.S. Census Bureau, 2010), consideration of the cultural appropriateness of EBTs will continue to be an important focus for therapists, whether in the research or practice domain. Here, we have identified a few concrete steps one could take to help adapt EBTs for use with ethnically/culturally diverse child clients. Next, we turn to how another level in the MHSE model, the provider, may influence the dissemination of EBTs.
Therapist Factors
Although they represent the primary focus of nearly all treat- ment research to date, differences at the child level are not the only relevant factors. Important differences have been noted between therapists in research studies and those working in the community (e.g., Weisz, Southam-Gerow, Gordis, & Connor-Smith, 2003). For example, therapists in research studies tend to be doctoral students working with the treatment developer who receive inten- sive training and supervision from the treatment developer (or an expert in the treatment model being tested), and carry small fo- cused caseloads with no productivity quota (i.e., not required to bill a specific number of hours each week). On the other hand, therapists in community settings are a diverse group, representing a large number of professional training backgrounds (psychology, social work, family therapy, counseling, etc.), with varied and usually large caseloads and high productivity demands, and re- ceive considerably less supervision, especially when considered on a minutes-per-case basis.
These differences are important for professional psychologists to consider, whether in the role of a therapist asked to learn a new EBT or in the role of a trainer/supervisor of an EBT. Dissemina- tion of EBTs to community settings will likely require therapist training and the topic of training has become the focus of concep- tual and empirical work (e.g., Beidas & Kendall, 2010; Herschell, Kolko, Baumann, & Davis, 2010). A few general guidelines emerge from the literature on therapist training, though the empir- ical basis of some of the guidelines is not ideal. First, a primary method used to train therapists in treatment models, the workshop approach, has been found ineffective at changing provider behav- ior in many cases2 (e.g., Beidas & Kendall, 2010; Grimshaw et al., 2001; Herschell et al., 2010). Most such workshops rely on passive training approaches and involve limited if any follow-up after the training day (or days). Thus, the workshop approach alone may not be sufficient for ensuring the application of new and complex behaviors, such as delivering a structured therapy protocol.
What other options exist? Herschell et al. (2010) identified several, including (a) treatment manuals and self-directed train-
2 Training therapists in a new treatment model is a more complex goal than training them to use a new documentation system, for example. Some training goals are well suited for rather simple training approaches whereas others will require a more complex approach.
529D&I RESEARCH FOR YOUTH EVIDENCE-BASED TREATMENTS
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
ings, (b) intensive workshops (observation and feedback during the training, consultation and/or coaching after), (c) pyramid training (i.e., train-the-trainer or cascading), and (d) multicomponent ap- proaches (i.e., combinations of manuals, live trainings, expert consultation, monitoring of taped sessions, and booster training sessions. Herschell et al.’s (2010) review concluded that the mul- ticomponent approach produced superior training outcomes (e.g., improvements in therapist knowledge, acceptable fidelity ratings, child outcomes), though the literature remains a sparse one.
At a more molecular level, Lyon, Stirman, Kerns, and Bruns (2011) identified potentially useful training strategies used in diverse fields (medicine, education). First, they described aca- demic detailing, an approach involving EBT-naı̈ve therapists re- questing that an EBT-trained therapist consult with them in their work settings. In academic detailing, the therapist-in-training pro- vides baseline information about his or her background and knowl- edge of various practices so that the trainer can create a tailored and efficient training plan, for example by focusing on areas with the largest production (i.e., does not use specific practices) or knowledge (i.e., unfamiliar with specific treatment approaches) gaps. A second approach, problem-based learning, combines col- laboration and self-directed learning in a unique way. Case exam- ples are generally used as a starting point, with the trainer and trainees working collaboratively to (a) analyze the problem (e.g., how to devise a treatment plan for the case); (b) identify and justify possible solutions, sometimes requiring acquisition of new knowl- edge; (c) select a solution and take the necessary steps to enact the plan; and (d) report outcomes back to the group. One relevant aspect of this approach for dissemination of EBTs is the direct encouragement of trainees to identify and address knowledge gaps to solve problems. Finally, Lyon et al. (2011) described coaching, (by expert or peer), as an approach that follows formal training. Expert coaching “involves a person with expertise in the content . . . providing direct feedback and advice” (Lyon et al., 2011, p. 246). Peer coaching is when peers, for example two therapists, give each other constructive feedback aimed at improving perfor- mance in a particular domain (e.g., providing therapy, teaching).
A training “how-to” literature is emerging and will be a good guide for professional psychologists who find themselves in the role of trainer and/or supervisor of other providers learning EBTs. Before setting the training date, however, Beidas and Kendall (2010) cautioned that a consideration of the complex systems in which therapists are embedded is needed before identifying a method for training (cf. MHSE model). Specifically, they noted that training efforts will be influenced by therapist variables, including basic demographic characteristics (e.g., gender, race), previous training background, theoretical orientation, professional guild, and therapist attitudes toward EBTs. Several studies affirm the importance of considering such therapist characteristics. For example, several studies have found that many therapists do not view EBTs favorably for a variety of reasons such as rigidity of treatment manual (e.g., Aarons, 2004; Brookman-Frazee, Garland, Taylor, & Zoffness, 2009; Jensen-Doss, Hawley, Lopez, & Oster- berg, 2009). Multiple factors have been investigated as potential moderators of therapist attitudes, including knowledge of EBTs (positively related to attitudes), formal education level (mixed evidence), and therapist experience (no relation to attitudes; e.g., Jensen-Doss et al., 2009; Nakamura, Higa-McMillan, Okamura, & Shimabukuro, 2011).
Thus, a few tentative suggestions emerge for the professional psychologist tasked with training therapists in an EBT. First, know the audience; survey the trainees on their background, knowledge, and attitudes about EBTs. Second, if possible, increase therapist knowledge about EBTs prior to training, thereby potentially im- proving attitudes toward EBTs and thus, facilitate training efforts. When therapists are trained in EBTs, studies suggest that their attitudes toward EBTs improve, though the effect may be specific to the EBT being trained and time limited (e.g., Borntrager, Chor- pita, Higa, & Weisz, 2009; Jensen-Doss et al., 2008). Further, more evidence is needed on whether or not training leads to increases in actual behavior (Lopez, Osterberg, Jensen-Doss, & Rae, 2011).
Although professional psychologists may find themselves in the role of trainee as EBTs are disseminated, more likely they will be in the role of trainer and/or supervisor. For such psychologists, Decker, Jameson, and Naugle (2011) enumerated a set of relevant outcomes related to therapist training that could be used. For example, measures of therapist perceptions of the training itself are needed. Further, changes in therapist attitudes should be assessed over time. As well, knowledge and skills, via self-report and/or observation (e.g., coding), should be monitored. At this point, our science related to treatments far outpaces our science related to training. As such, professional psychologists are likely to play an important role in the future of dissemination and implementation research.
In this section, we described the importance of therapist training for dissemination of EBTs, highlighting action steps for profes- sional psychologists, including desirable aspects of therapist train- ing models and important variables to measure when training therapists. Next, we turn to the last of the factors thought to influence dissemination efforts: mental health systems.
Systems Factors
Professional psychologists more and more find themselves in managerial, directorial, and/or administrative roles in behavioral health organizations. Accordingly, awareness of and attention to the system level of the MHSE model (e.g., federal, state, and local polices, insurance companies policies) is becoming increasingly important. When considering support for the dissemination of EBTs at the system level, numerous interacting factors become important to consider. In this section, we highlight several of the concrete issues that may be faced by professional psychologists when implementing EBTs in child-serving systems. Specifically, we describe the importance of (a) coordinating clinical and admin- istrative functions; (b) credentialing; (c) system constraints (e.g., documentation standards, requirements); and (d) quality monitor- ing efforts.
An overarching distinction that often pervades current systems is the division between clinical services and administrative oper- ations. Common clinical service functions include: (a) direct care, (b) supervision, and (c) clinical support (e.g., scheduling, docu- mentation, etc.). Common administrative functions include (a) governance and planning, (b) policy and standard setting, (c) utilization management (UM), (d) performance or quality manage- ment, (e) credentialing, (f) finance and business development, (g) workforce development, and (h) network relations (e.g., provider relations, customer relations, public relations, etc.). In addition, as
530 SOUTHAM-GEROW, RODRÍGUEZ, CHORPITA, AND DALEIDEN
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
a strategy for coordinating services across multiple system or stakeholder groups, case management or care coordination is often provided as a customer service that may straddle the line of clinical and administrative services (e.g., aligning clinical and administra- tive resources).
Each of these functions may either support or inhibit the use of EBTs in a system. Pursuit of a large-scale systematic implemen- tation of EBTs may call for comprehensive consideration of these functions. When an EBT is implemented in the context of an operating system, clinical and administrative functions are often encountered as constraints on the implementation. For example, if a team of providers would like to adopt a new practice, without a system level financing intervention, a defined set of billing codes may need to be mapped to the components of the new practice (e.g., an office visit code will be used for child session, a planning or consultation code will be used for a teacher session, collateral or family code will be used for a parent session, room and board will be billed to a different funding agency). On the other hand, system administrators seeking to implement such a program may consider whether financing could be restructured to allow a bundled rate or whether provider contracts could be established under a cost- reimbursement—rather than unit-rate structure. At a minimum, professional psychologists need to be aware of the importance of administrative and clinical service collaboration to facilitate changes in the system, including especially implementation of a new EBT. By working together to identify potential problems and fashion solutions leveraging their unique expertise in the system, therapists and administrators (both roles of professional psychol- ogists) will enhance the likelihood of the success of the dissemi- nation efforts.
Credentialing, that is tracking adherence to predefined standards for the workforce (e.g., licensure, certification), may also play a key role in EBT implementation and may be a function that therapists need to perform. System level credentialing varies widely, and decisions about how broad or narrow to set creden- tialing requirement have huge implications for practice implemen- tation. Professional licensing standards are among the broadest credentialing requirements. The types of licenses approved vary by state, meaning that systems must manage and have regulations for a host of professionals. Furthermore, the types of services that may be delivered by licensed, unlicensed but supervised, unlicensed professionals, or paraprofessionals vary widely. Specific to EBTs, there is no current standard for the credentialing of providers in the delivery of specific EBTs. Although many EBTs have developed specific standards for providers to be certified or approved to provide the EBT, those standards differ by EBT. And many EBTs have no standards at all. Systems may also set their own creden- tialing requirements, for example requiring model-specific certifi- cation by EBT developers to qualify for reimbursement or may set performance standards requiring that a defined proportion of ser- vices be delivered by providers with model-specific certifications. Given the complexity within the service system, professional psy- chologists involved in dissemination and implementation efforts will need to be familiar with credentialing.
Numerous other system policies and standards may support or inhibit EBT implementation and professional psychologists in- volved in dissemination of EBTs will need to not only be aware of these but be prepared to take steps to create policies and standards that will support EBTs. Although supervision requirements are
increasingly common in child serving systems, EBT implementa- tion may be facilitated or inhibited by the extent that the nature and volume of supervision required is consistent with the supervision framework for that EBT model. If multiple EBT models have different supervision requirements, tough decisions about balanc- ing model adherence, productivity, and financial benefit may be required; these are exactly the sorts of decisions that professional psychologists will face as the clinical director, for example, of an agency attempting to implement an EBT.
Finally, caseload requirements and/or market pressures that drive caseload size may also be relevant to EBT implementation. Proper implementation of some EBTs includes a defined caseload limit, whereas others may provide guidelines, and still others remain silent on the issue. The extent to which the prescribed caseload limits fit (or not) within a particular system is obviously a key issue. The dissemination literature has suggested that one of the factors affecting the ability to effectively implement organiza- tional change is the availability of “slack” resources to dedicate toward new initiatives (Fixsen et al., 2005; Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004). Caseload burden may be one indicator of resource demands, and a common complaint of therapists is that there may not be “enough time” to manage existing caseloads (Hamilton, Daleiden, & Dopson, 2011) much less tolerate a period of reduced productivity during adoption of a new clinical model. Again, therapists acting as the lead in a dissemination effort will need to consider how to manage caseload throughout that effort, perhaps balancing the needs of therapists for lighter caseloads while learning a new approach with the needs of the agency for productivity to maintain fiscal soundness.
The last system-level consideration is related to the definition of quality and the relative priority assigned to managing performance in systems. One common approach to defining quality is to em- phasize the access and availability of services. Although this approach may help increase penetration of services and reduce unmet need, it may have a deleterious effect on the implementation of EBTs by narrowing organizational focus and increasing pro- ductivity pressures without a counterbalancing quality/integrity pressure (Hamilton et al., 2011). That is, emphasis on the quantity of services over the quality of those services runs the risk of poorer child outcomes and poorer therapist morale (Hamilton et al., 2011). Alternatively, defining quality in terms of maintaining fidelity to EBTs may contribute to more favorable outcomes (e.g., Hogue et al., 2008; Schoenwald, Sheidow, & Chapman, 2009), though such an approach may increase costs for the agency through the need to monitor fidelity. Again, given their unique skill set including knowledge of treatments and knowledge of scientific methods, professional psychologists may find them- selves tasked with creating quality and performance measurement tools to help a system measure and improve the quality of services delivered.
For professional psychologists whose primary focus is provision of direct services in agencies or systems, knowledge of these systems-level factors may help them to collaborate more effec- tively in dissemination efforts. For those professional psycholo- gists in mixed or primarily administrative roles, however, these factors are even more important. By taking the right steps, a psychologist can guide an organization in a planful manner, align- ing administrative and clinical functions to maximize the impact of an EBT initiative. For example, one can work to identify the
531D&I RESEARCH FOR YOUTH EVIDENCE-BASED TREATMENTS
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
administrative barriers to implementation in advance, providing time to generate the processes needed to reduce or eliminate those barriers. Indeed, the overall focus of the article—that consideration of the whole of the MHSE model may be needed to enact maxi- mum impact of dissemination efforts—is itself a systems-level intervention. And psychologists are uniquely suited for the task ahead. By training, we take a broad and ecological view of inter- vention. Doing so when disseminating EBTs, then, could come to us naturally.
Summary
The challenges of bridging the science-practice gap in children’s mental health led to the elaboration of a field of inquiry, dissem- ination and implementation science. One focus of this work has been on identifying barriers to dissemination and how to overcome them. In this article, we outlined the Mental Health Service Eco- logical (MHSE) model as a framework for understanding some of these barriers. We then described proposed solutions at the three of the levels of the MHSE model. The development and testing of child/adolescent EBTs will require a focus across multiple levels of the ecology to maximize the public health impact of clinical science. We must grapple with how to address and account for child, therapist, and system differences related to the delivery of therapies for childhood emotional and behavioral problems. Al- though some directions were identified in this review article, we are hopeful that the growing legions of psychologists and other scientists whose focus is on dissemination and implementation research will continue to push the envelope to accomplish the goal of identifying how to deliver the best services to the most children and families.
References
Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence-based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6, 61–74. doi:10.1023/B: MHSR.0000024351.12294.65
Atkins, M. S., Frazier, S. L., Birman, D., Adil, J. A., Jackson, M., Graczyk, P. A., . . . McKay, M. (2006). School-based mental health services for children living in high poverty urban communities. Administration and Policy in Mental Health and Mental Health Services Research, 33, 146 –59. doi:10.1007/s10488-006-0031-9
Baker-Ericzén, M. J., Hurlburt, M. S., Brookman-Frazee, L. B., Jenkins, M. M., & Hough, R. L. (2010). Comparing child, parent, and family characteristics in usual care and empirically supported treatment re- search samples for children and disruptive behavior disorders. Journal of Emotional and Behavioral Disorders, 18, 82–99. doi:10.1177/ 1063426609336956
Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence- based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology: Science and Practice, 17, 1–30. doi: 10.1111/j.1468-2850.2009.01187.x
Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adapta- tion and development of psychosocial treatments with Hispanics. Jour- nal of Abnormal Child Psychology, 23, 67– 87. doi:10.1007/ BF01447045
Bernal, G., Jimenez-Chafey, M. I., & Rodriguez, M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence- based practice. Professional Psychology: Research and Practice, 40, 361–368. doi:10.1037/a0016401
Borntrager, C. F., Chorpita, B. F., Higa, C., & Weisz, J. R. (2009). Provider attitudes toward evidence-based practices: Are the concerns with the evidence or with the manuals? Psychiatric Services, 60, 677– 681. doi: 10.1176/appi.ps.60.5.677
Brookman-Frazee, L., Garland, A. F., Taylor, R., & Zoffness, R. (2009). Therapists’ attitudes towards psychotherapeutic strategies in community-based psychotherapy with children with disruptive behavior problems. Administration and Policy in Mental Health and Mental Health Services Research, 36, 1–12. doi:10.1007/s10488-008-0195-6
Cappella, E., Frazier, S., Atkins, M., Schoenwald, S., & Glisson, C. (2008). Enhancing schools’ capacity to support children in poverty: An ecolog- ical model of school-based mental health services. Administration and Policy in Mental Health and Mental Health Services Research, 35, 395– 409. doi:10.1007/s10488-008-0182-y
Chambless, D. L., Sanderson, W. C., Shoham, V., Johnson, S. B., Pope, K. S., Crits-Christoph, P., . . . McCurry, S. (1996). An update on em- pirically validated therapies. The Clinical Psychologist, 49, 5–18.
Chorpita, B. F. (2003). The frontier of evidence-based practice. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for chil- dren and adolescents (pp. 42–59). New York, NY: Guilford.
Chorpita, B. F., & Daleiden, E. (2010). Building evidence-based systems in children’s mental health. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 482– 499). New York, NY: Guilford Press.
Chorpita, B. F., Daleiden, E. L., Ebesutani, C., Young, J. Becker, K. D., Nakamura, B. J., . . . Starace, N. (2011). Evidence-based treatments for children and adolescents: An updated review of indicators of efficacy and effectiveness. Clinical Psychology: Science and Practice, 18, 153– 172. doi:10.1111/j.1468-2850.2011.01247.x
Chu, B. C., Merson, R. A., Zandberg, L. J., & Margaret, A. (2012). Calibrating for comorbidity: Clinical decision-making in youth depres- sion and anxiety. Cognitive and Behavioral Practice, 19, 5–16. doi: 10.1016/j.cbpra.2010.10.005
Clarke, G., Debar, L., Lynch, F., Powell, J., Gale, J., O’Connor, E., . . . Hertet, S. (2005). A randomized effectiveness trial of brief cognitive- behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 888 – 898. doi:10.1016/S0890-8567(09)62194-8
Copeland, W. E., Shanahan, L., Costello, E. J., & Angold, A. (2009). Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Archives of General Psychiatry, 66, 764 –772. doi: 10.1001/archgenpsychiatry.2009.85
Cunningham, P., Foster, S., & Henggeler, S. (2002). The elusive concept of cultural competence. Children’s Service: Social Policy, Research, and Practice, 5, 231–243. doi:10.1207/S15326918CS0503_7
Curry, J., Rohde, P., Simons, A., Silva, S., Vitiello, B., Kratochvil, C., . . . March, J. (2006). Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). Journal of the American Academic Child & Adolescent Psychiatry, 45, 1427–1439. doi:10.1097/01.chi. 0000240838.78984.e2
Damschroder, L., & Hagedorn, H. J. (2011). A guiding framework and approach for implementation research in substance use disorders treat- ment. Psychology of Addictive Behaviors, 25, 194 –205. doi:10.1037/ a0022284
Decker, S. E., Jameson, M. T., & Naugle, A. E. (2011). Therapist training in empirically supported treatments: A review of evaluation methods for short-and long-term outcomes. Administration and Policy in Mental Health and Mental Health Services Research, 38, 254 –286. doi: 10.1007/s10488-011-0360-1
Domenech-Rodrı́guez, M. M., Baumann, A., & Schwartz, A. (2011). Cultural adaptation of an empirically supported intervention: From the- ory to practice in a Latino/a community context. American Journal of Community Psychology, 47, 170 –186. doi:10.1007/s10464-010-9371-4
Domenech-Rodrı́guez, M. M., & Wieling, E. (2005). Developing culturally
532 SOUTHAM-GEROW, RODRÍGUEZ, CHORPITA, AND DALEIDEN
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
appropriate, evidence-based treatments for interventions with ethnic minority populations. In M. Rastogi & E. Weiling (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 313–333). Thousand Oaks, CA: Sage. doi:10.4135/9781452231662.n18
Dwight-Johnson, M., Sherbourne, C. D., Liao, D., & Wells, K. B. (2000). Treatment preferences among depressed primary care patients. Journal of General Internal Medicine, 15, 527–534. doi:10.1046/j.1525- 1497.2000.08035.x
Ehrenreich, J., Goldstein, C., Wright, L. R., & Barlow, D. H. (2009). Development of a unified protocol for the treatment of emotional dis- orders in youth. Child & Family Behavior Therapy, 31, 20 –37. doi: 10.1080/07317100802701228
Ehrenreich-May, J., Southam-Gerow, M. A., Hourigan, S. E., Wright, L. R., Pincus, D. B., & Weisz, J. R. (2011). Characteristics of anxious and depressed youth seen in two different clinical contexts. Administra- tion and Policy in Mental Health, 38, 398 – 411. doi:10.1007/s10488- 010-0328-6
Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Pub- lication #231).
Glisson, C., & Schoenwald, S. K. (2005). The ARC organizational and community intervention strategy for implementing evidence-based chil- dren’s mental health treatments. Mental Health Services Research, 7, 243–259. doi:10.1007/s11020-005-7456-1
Glisson, C., Schoenwald, S. K., Kelleher, K., Landsverk, J., Hoagwood, K. E., Mayberg, S., & Green, P. (2008). Therapist turnover and new program sustainability in mental health clinics as a function of organi- zational culture, climate, and service structure. Administration and Pol- icy in Mental Health and Mental Health Services Research, 35, 124 – 133. Springer. doi:10.1007/s10488-007-0152-9
Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82, 581– 629. doi:10.1111/j.0887-378X.2004.00325.x
Griffith, J. D., Knight, D. K., Joe, G. W., & Simpson, D. D. (1998). Implications of family and peer relations for treatment engagement and follow-up outcomes: An integrative model. Psychology of Addictive Behaviors, 12, 113–126. doi:10.1037/0893-164X.12.2.113
Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., . . . O’Brien, M. A. (2001). Changing provider behaviour. An overview of systematic reviews of interventions. Medical Care, 39, II2–I45. doi:10.1097/00005650-200108002-00002
Hamilton, J., Daleiden, E., & Dopson, S. (2011). Implementing evidence- based practices for youth in an HMO: The roles of external ratings and market share. Administration and Policy in Mental Health and Mental Health Services Research, 38, 203–210. doi:10.1007/s10488-011- 0343-2
Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The role of therapist training in the implementation of psychosocial treat- ments: A review and critique with recommendations. Clinical Psychol- ogy Review, 30, 448 – 466. doi:10.1016/j.cpr.2010.02.005
Hoagwood, K., & Olin, S. (2002). The NIMH blueprint for change report: Research priorities in child and adolescent mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 760 –767. doi:10.1097/00004583-200207000-00006
Hoagwood, K., Cavaleri, M., Olin, S. S., Burns, B. J., Slaton, E., Gruttardo, D., & Hughes, R. (2010). Family support in children’s mental health: A review and synthesis. Clinical Child and Family Psychology Review, 13(1), 1– 45. doi:10.1007/s10567-009-0060-5
Hogue, A., Henderson, C. E., Dauber, S., Barajas, P. C., Fried, A., & Liddle, H. A. (2008). Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. Journal
of Consulting and Clinical Psychology, 76, 544 –555. doi:10.1037/0022- 006X.76.4.544
Huey, S., & Polo, A. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psy- chology, 37, 262–301. doi:10.1080/15374410701820174
Hwang, W. (2006). The Psychotherapy Adaptation and Modification Framework (PAMF): Application to Asian Americans. American Psy- chologist, 61, 702–715. doi:10.1037/0003-066X.61.7.702
Hwang, W. (2009). The formative method for adapting psychotherapy (FMAP): A community-based developmental approach to culturally adapting therapy. Professional Psychology: Research and Practice, 40, 369 –377. doi:10.1037/a0016240
Jensen-Doss, A., Hawley, K., Lopez, M., & Osterberg, L. (2009). Using evidence-based treatments: The experiences of youth providers working under a mandate. Professional Psychology: Research and Practice, 40, 417– 424. doi:10.1037/a0014690
Lau, A. S. (2006). Making a case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent train- ing. Clinical Psychology: Science and Practice, 13, 295–310. doi: 10.1111/j.1468-2850.2006.00042.x
Lim, C. S., Follansbee-Junger, K. W., Crawford, M. S., & Janicke, D. M. (2011). Treatment outcome research in rural pediatric populations: The challenge of recruitment. Journal of Pediatric Psychology, 36, 696 –707. doi:10.1093/jpepsy/jsr018
Lopez, M., Osterberg, L., Jensen-Doss, A., & Rae, W. A. (2011). Effects of workshop training for providers under mandated use of an evidence- based practice. Administration and Policy in Mental Health and Mental Health Services Research, 38, 301–312. doi:10.1007/s10488-010- 0326-8
Lyon, A. R., Stirman, S. W., Kerns, S. E., & Bruns, E. J. (2011). Devel- oping the mental health workforce: Review and application of training approaches from multiple disciplines. Administration and Policy in Mental Health, 38, 238 –253. doi:10.1007/s10488-010-0331-y
Mak, W. W. S., Law, R. W., Alvidrez, J., & Perez-Stable, E. J. (2007). Gender and ethnic diversity in NIMH-funded clinical trials: Review of a decade of published research. Administration and Policy in Mental Health and Mental Health Services Research, 34, 497–503. doi:10.1007/ s10488-007-0133-z
Martinez, C. R., & Eddy, M. (2005). Effects of culturally adapted Parent Management Training on Latino youth behavioral health outcomes. Journal of Consulting and Clinical Psychology, 73, 841– 851. doi: 10.1037/0022-006X.73.5.841
McCabe, K., & Yeh, M. (2009). Parent-child interaction therapy for Mexican Americans: A randomized clinical trial. Journal of Clinical Child and Adolescent Psychology, 38, 753–759. doi:10.1080/ 15374410903103544
McKay, M. M., Hibbert, R., Hoagwood, K., Rodriguez, J., Murray, L., Le- gurski, J., & Fernandez, D. (2004). Integrating evidence-based engagement interventions into “real world” child mental health setting. Brief Treatment and Crisis Intervention, 4, 177–186. doi:10.1093/brief-treatment/mhh014
Miller, L. M., Southam-Gerow, M. A., & Allin, R. B. (2008). Who stays in treatment? Child and family predictors of youth client retention in a public mental health agency. Child Youth Care Forum, 37, 153–170. doi:10.1007/s10566-008-9058-2
Nakamura, B. J., Higa-McMillan, C., Okamura, K. H., & Shimabukuro, S. (2011). Knowledge of and attitudes towards evidence-based practice in community child mental health practitioners. Administration and Policy in Mental Health, 38, 287–300. doi:10.1007/s10488-011-0351-2
Nicolas, G., Arntz, D. L., Hirsch, B., & Schmiedigen, A. (2009). Cultural adaptation of a group treatment for Haitian American adolescents. Pro- fessional Psychology: Research and Practice, 40, 378 –384. doi: 10.1037/a0016307
Nock, M. K., & Kazdin, A. E. (2001). Parent expectancies for child
533D&I RESEARCH FOR YOUTH EVIDENCE-BASED TREATMENTS
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
therapy: Assessment and relation to participation in treatment. Journal of Child & Family Studies, 10, 155–180. doi:10.1023/A:1016699424731
Proctor, E. K. Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36, 24 –34. doi:10.1007/s10488-008-0197-4
Rosselló, J., Bernal, G., & Rivera-Medina, C. (2008). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 14, 234 –245. doi: 10.1037/1099-9809.14.3.234
Schoenwald, S. K., & Hoagwood, K. (2001). Effectiveness, transportabil- ity, and dissemination of interventions: What matters when? Psychiatric Services, 52, 1190 –1197. doi:10.1176/appi.ps.52.9.1190
Schoenwald, S. K., Sheidow, A. J., & Chapman, J. E. (2009). Clinical supervision in treatment transport: Effects on adherence and outcomes. Journal of Consulting and Clinical Psychology, 77, 410 – 421. doi: 10.1037/a0013788
Siqueland, L., Crits-Christoph, P., Gallop, B., Gastfriend, D., Lis, J., Frank, A., . . . Luborsky, L. (2002). Who starts treatment: Engagement in the NIDA Collaborative Cocaine Treatment Study. The American Journal on Addictions, 11, 10 –23. doi:10.1080/10550490252801602
Southam-Gerow, M. A., Chorpita, B. F., Miller, L. M., & Gleacher, A. A. (2008). Are children with anxiety disorders privately-referred to a uni- versity clinic like those referred from the public mental health system? Administration and Policy in Mental Health and Mental Health Services Research, 35, 168 –180. doi:10.1007/s10488-007-0154-7
Southam-Gerow, M. A., Ringeisen, H. L., & Sherrill, J. T. (2006). Inte- grating interventions and services research: Progress and prospects. Clinical Psychology: Science and Practice, 13, 1– 8. doi:10.1111/j.1468- 2850.2006.00001.x
Southam-Gerow, M. A., Weisz, J. R., Chu, B. C., McLeod, B. D., Gordis, E. B., & Connor-Smith, J. K. (2010). Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1043–1052. doi:10.1016/j.jaac.2010.06.009
Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440 – 448. doi:10.1037/0003- 066X.53.4.440
Swenson, C. C., Schaeffer, C. M., Henggeler, S. W., Faldowski, R., & Mayhew, A. M. (2010). Multisystemic therapy for child abuse and neglect: A randomized effectiveness trial. Journal of Family Psychol- ogy, 24, 497–507. doi:10.1037/a0020324
Tang, M., Hill, K., & Boudreau, A. (2008). Medicaid managed care and the unmet need for mental health care among children with special health care needs. Health Services Research, 43, 882–900. doi:10.1111/j.1475- 6773.2007.00811.x
U.S. Census Bureau. (2000). 2010 Census Shows America’s Diversity. Retrieved April 16, 2012 from http://2010.census.gov/news/releases/ operations/cb11-cn125.html
Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., . . . Research Network on Youth Mental Health. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69, 274 –282. doi: 10.1001/archgenpsychiatry.2011.147
Weisz, J. R., Southam-Gerow, M. A., Gordis, E. B., & Connor-Smith, J. K. (2003). Primary and secondary control enhancement training for youth depression: Applying the Deployment-Focused Model of treatment de- velopment and testing. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence- based treatments for children and adolescents (pp. 165–183). New York, NY: Guilford.
Wood, J. J., Chiu, A. W., Hwang, W., Jacobs, J., & Ifekwunigwe, M. (2008). Adapting cognitive-behavioral therapy for Mexican American students with anxiety disorders: Recommendations for school psychol- ogists. School Psychology Quarterly, 23, 515–532. doi:10.1037/1045- 3830.23.4.515
Yeh, M., McCabe, K., Hough, R. L., Lau, A., Fakhry, F., & Garland, A. (2005). Why bother with beliefs? Examining relationships between race/ethnicity, parental beliefs about causes of child problems, and mental health service use. Journal of Consulting and Clinical Psychol- ogy, 73, 800 – 807. doi:10.1037/0022-006X.73.5.800
Received December 21, 2011 Revision received May 9, 2012
Accepted May 14, 2012 �
534 SOUTHAM-GEROW, RODRÍGUEZ, CHORPITA, AND DALEIDEN
T hi
s do
cu m
en t i
s co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
tio n
or o
ne o
f i ts
a lli
ed p
ub lis
he rs
. T
hi s
ar tic
le is
in te
nd ed
s ol
el y
fo r t
he p
er so
na l u
se o
f t he
in di
vi du
al u
se r a
nd is
n ot
to b
e di
ss em
in at
ed b
ro ad
ly .
