EXECUTIVE SUMMARY

Improving Service Delivery for

Children Affected by Trauma 

An Implementation Study of Children’s Institute, Inc.

Michelle S. Manno

Louisa Treskon 

 

 

August 2016
This material is based upon work supported by the Social Innovation Fund (SIF), a program of the 

Corporation for National and Community Service (CNCS). The Edna McConnell Clark Foundation 

and the SIF include support from CNCS and 15 private co-investors: The Edna McConnell Clark 

Foundation, The Annie E. Casey Foundation, The Duke Endowment, The William and Flora 

Hewlett Foundation, The JPB Foundation, George Kaiser Family Foundation, The Kresge Foundation, Open Society Foundations, The Penzance Foundation, The Samberg Family Foundation, The 

Charles and Lynn Schusterman Family Foundation, The Starr Foundation, Tipping Point Community, The Wallace Foundation, and the Weingart Foundation.

Dissemination of MDRC publications is supported by the following funders that help finance 

MDRC’s public policy outreach and expanding efforts to communicate the results and implications of our work to policymakers, practitioners, and others: The Annie E. Casey Foundation, 

Charles and Lynn Schusterman Family Foundation, The Edna McConnell Clark Foundation, Ford 

Foundation, The George Gund Foundation, Daniel and Corinne Goldman, The Harry and Jeanette 

Weinberg Foundation, Inc., The JBP Foundation, The Joyce Foundation, The Kresge Foundation, 

Laura and John Arnold Foundation, Sandler Foundation, and The Starr Foundation.

 

In addition, earnings from the MDRC Endowment help sustain our dissemination efforts. Contributors to the MDRC Endowment include Alcoa Foundation, The Ambrose Monell Foundation, 

Anheuser-Busch Foundation, Bristol-Myers Squibb Foundation, Charles Stewart Mott Foundation, Ford Foundation, The George Gund Foundation, The Grable Foundation, The Lizabeth and 

Frank Newman Charitable Foundation, The New York Times Company Foundation, Jan Nicholson, Paul H. O’Neill Charitable Foundation, John S. Reed, Sandler Foundation, and The Stupski 

Family Fund, as well as other individual contributors.

The findings and conclusions in this report do not necessarily represent the official positions or 

policies of the funders. 

For information about MDRC and copies of our publications, see our website: www.mdrc.org. 

Copyright © 2016 by MDRC®. All rights reserved.
iii

Overview 

The Children’s Institute, Inc. (CII), is a multiservice organization in Los Angeles, California, that 

combines clinical mental health and other supportive services to meet the needs of children and their 

families who have been affected by trauma, such as physical or sexual abuse, domestic violence, or 

violence in the community. Through its Integrated Service Model, CII provides holistic and coordinated support to children and families by potentially engaging them in multiple services: clinical 

services to address children’s mental health needs, programs for parents and guardians to help them 

better support their children, and youth activities to develop protective factors. The comprehensive

nature of this model sets it apart from the often fragmented and uncoordinated child welfare system. 

A central aspect of CII’s model is using evidence-based practices — highly specified treatment 

models that research has shown to be effective in treating a targeted population — in its clinical 

services.

The CII evaluation had two main components: an implementation study of CII’s service model and a 

study of CII’s delivery of evidence-based practices, including an in-depth fidelity study of its 

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) services. 

Key Findings

•

•

•

•

CII is achieving its goal of engaging clients in multiple services to holistically meet their needs.

A majority of clients receiving clinical services from CII also participated in another service at 

the organization.

Analysis of management information system data indicates that nearly a third of the children 

engaged in clinical services received an evidence-based practice. While little is known about 

national norms for the use of evidence-based practices, the study’s findings suggest that CII is a 

leader in providing them.

Analysis also indicates that the dosage levels of Functional Family Therapy and TF-CBT — 

two prominent evidence-based practices at CII — were both in line with model expectations.

The in-depth fidelity study of TF-CBT indicated that CII’s implementation of the treatment 

model was aligned with that of other community-based organizations in similar fidelity studies. The average client had at least a 50 percent chance of receiving half of the model’s core 

components.

A Technical Resource for this report presents the complete set of findings from the in-depth fidelity 

study of CII’s delivery of TF-CBT and is available on the MDRC website. 

CII is also involved in MDRC’s Building Bridges and Bonds study of fatherhood programs, funded 

by the U.S. Department of Health and Human Services.

v 

Preface

There is overwhelming evidence that traumatic experiences in childhood — such as physical or 

sexual assault, gang violence, domestic violence, or sudden loss of a loved one — can lead to 

poor outcomes in adulthood. While the child welfare field is extensive and works to improve 

the life prospects of trauma-affected children and families, the available services are nevertheless often fragmented and uncoordinated. Research has identified evidence-based practices that 

improve outcomes for these children and families, and there has been a push at the federal level 

in recent years to increase the use of such practices in children’s mental health care. However, 

many of the current services available lack evidence of their effectiveness.

In this context, the Los Angeles-based Children’s Institute, Inc. (CII), operates its wide 

range of programs and services, including clinical mental health services, early child care and 

Head Start programs, programs for parents and guardians, and youth development activities. 

Integrating and coordinating these services to address the holistic needs of children and families 

is a critical component of CII’s service model, as is the use of evidence-based practices in 

mental health treatment when appropriate.

This report describes how in implementing its Integrated Service Model CII sought to 

overcome the barriers associated with the fragmented and uncoordinated child welfare system 

through an approach that attempts to identify clients’ full range of needs and ensure they receive 

all the support required to address those needs. It offers lessons in how multiservice organizations such as CII can structure services to meet the holistic needs of clients. Integrating services 

as CII has done, however, is not without its challenges. Tailoring services to the varied needs of 

each client requires navigating the complex funding system on which multiservice organizations 

rely, and which includes public agencies, private foundations, and health insurance providers.

The report also adds to the understanding of the challenges of implementing evidencebased practices in community-based settings, where the highly specified protocols of these

practices meet the realities of providing services in high-needs and under-resourced communities. The in-depth fidelity study of CII’s delivery of Trauma-Focused Cognitive Behavioral 

Therapy services highlighted some of the difficulties therapists encounter when delivering a 

structured treatment to high-needs clients. The study found that therapists at CII did not provide 

all of the model’s required treatment components, which is consistent with findings from other, 

similar studies of community-based providers. This finding suggests the need for robust and 

low-cost tools to help providers deliver evidence-based treatments with fidelity. 

Gordon L. Berlin 

President, MDRC

vii

Acknowledgments

This report is based upon work supported by the Social Innovation Fund (SIF), a major White 

House initiative and program of the Corporation for National and Community Service (CNCS). 

The SIF combines public and private resources with the goal of increasing the impact of 

innovative, community-based solutions that have compelling evidence of improving the lives of 

people in low-income communities throughout the United States.

The Edna McConnell Clark Foundation and the SIF include support from CNCS and 15 

private co-investors: The Edna McConnell Clark Foundation, The Annie E. Casey Foundation, 

The Duke Endowment, The William and Flora Hewlett Foundation, The JPB Foundation, 

George Kaiser Family Foundation, The Kresge Foundation, Open Society Foundations, The 

Penzance Foundation, The Samberg Family Foundation, The Charles and Lynn Schusterman 

Family Foundation, The Starr Foundation, Tipping Point Community, The Wallace Foundation, 

and the Weingart Foundation. The Wallace Foundation provided additional support separate 

from its involvement with the SIF. This report would not have been possible without the 

support of these funders.

The assistance and support of many staff at Children’s Institute, Inc. (CII), were critical 

to the success of this study throughout all phases of the project. We especially want to thank 

current CII leadership, in particular Mary Emmons, Nina Revoyr, Jacqueline Atkins, Marion 

Dave, and Manuel Rivera. We also thank Steve Ambrose, Todd Sosna, and Cynthia ThompsonRandle, all of whom have since moved on from CII but who were critical to the success of this 

evaluation. Thanks also goes to Bruce Baker for his insight. Our data analysis would not have 

been possible without the assistance of Joshua Shaw, Jade Wong, Bill Monro, and Patrick Foy. 

A special thanks goes to all the CII staff we interviewed during our site visits. We would also 

like to thank CII’s funders and partners who participated in interviews, including representatives 

from Los Angeles County Departments of Mental Health and Children and Family Services.

The fidelity study of Trauma-Focused Cognitive Behavioral Therapy benefited from the 

efforts of many individuals. Patricia Chamberlain provided advice during the planning process. 

Our colleagues at the Medical University of South Carolina conducted the fidelity study: 

Rochelle Hanson, Jason Chapman, Sonja Schoenwald, Michael de Arellano, Carrie Jackson. 

CII’s clinical supervisors obtained informed consent from the clients. Many thanks go to the 

therapists who agreed to participate in the fidelity study. We also thank Matthew Dutcher who 

entered all the data from the Brief Practice Checklists for the fidelity study. We would be remiss 

if we also did not extend our deepest thanks to the clients and their families who agreed to 

participate in the fidelity study as well.
viii

The research team received useful feedback and encouragement throughout the project 

and comments on drafts of this report from Gabriel Rhoads, Jehan Velji, and Teresa Power at 

The Edna McConnell Clark Foundation.

At MDRC, John Martinez, Dan Bloom, David Butler, Rekha Balu, Kate Gualtieri, 

Robert Ivry, and Michael Johns provided thoughtful comments on several drafts of this report. 

We are grateful to Sally Dai for all the work she did to analyze the data. Melina Davis, Janae 

Bonsu, and Mifta Chowdhury assisted in qualitative data collection, and Mifta Chowdhury 

coordinated the production of the report. Christopher Boland edited the report, and Carolyn 

Thomas prepared it for publication.

The Authors
1 

Executive Summary 

Child abuse and neglect are significant problems in the United States, touching millions of lives 

each year. The U.S. Department of Health and Human Services reported that in fiscal year 

2012, 3.2 million children nationwide were the subject of a report to child protective services. 

The majority of youth in the child welfare system exhibit behavioral or social issues that are 

severe enough to warrant mental health treatment, a rate up to five times greater than mental 

health needs among their peers in the community who are not involved in the child welfare 

system.1

Recent trends in the children’s mental health care field have indicated that these behavioral and emotional issues can be largely attributed to trauma experienced earlier in life, which 

leads to “toxic stress responses” that can have a wide variety of adverse psychological and 

physiological consequences, some of which continue into adulthood.

2 Trauma can result from

many experiences and events, including physical or sexual assault, gang violence, domestic 

violence, serious accidents, sudden or violent loss of a loved one, and natural disasters.3 Children do not have to be the direct victims of violence to be affected by it; researchers have shown 

that exposure to community violence, such as hearing gun fire, has traumatic effects on children.4 Child welfare organizations throughout the country combat trauma in all its forms 

through a combination of prevention programs, direct services to affected families, and advocacy. While the lifelong impact of childhood mental illness and trauma is well documented, many 

children and youth do not receive the mental health treatment they need. Even when they do 

receive treatment, services may be inadequate or ineffective, and are often fragmented and 

uncoordinated.

 1

This estimate is based on studies across child welfare systems in several states, as well as recent results of 

the National Survey for Child and Adolescent Well-Being. John A. Landsverk, Barbara J. Burns, Leyla F. 

Stambaugh, and Jennifer A. Rolls Reutz, Mental Health Care for Children and Adolescents in Foster Care: 

Review of Research Literature (Seattle, WA: Casey Family Programs, 2006). 2

Wendy K. Silverman, Claudio D. Ortiz, Chockalingham Viswesvaran, Barbara J. Burns, David J. Kolko, 

Frank W. Putnam, and Lisa Amaya-Jackson, “Evidence-Based Psychosocial Treatments for Children and 

Adolescents Exposed to Traumatic Events,” Journal of Clinical Child and Adolescent Psychology 37, 1 

(2008): 156-183; Vincent J. Felitti, Robert F. Anda, Dale Nordenberg, David F. Williamson, Alison M. Spitz, 

Valerie Edwards, Mary P. Koss, and James S. Marks, “Relationship of Childhood Abuse and Household 

Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) 

Study,” American Journal of Preventive Medicine 14, 4 (1998): 245-258. 3

Child Welfare Committee, National Child Traumatic Stress Network, Child Welfare Trauma Training 

Tool Kit: Comprehensive Guide (2nd ed.) (Los Angeles and Durham, NC: National Center for Child Traumatic 

Stress, 2008). 4

Joy D. Osofsky (ed.), Children in a Violent Society (New York: Guilford Press, 1998).
2 

This report presents findings from a study of the Children’s Institute, Inc. (CII). A multiservice organization in Los Angeles, CII combines a broad range of clinical and nonclinical 

services to meet the needs of children and families who have been affected by trauma. Each 

year, CII serves more than 20,000 children and family members. CII’s range of activities, which 

it calls its Integrated Service Model, serve the “whole child, entire family.” Through its service

model, CII provides a broad range of supports that the child and family may need to overcome a 

history of abuse or trauma, including clinical services to address mental health needs, programs 

for parents and guardians to help them better support their children, and nonclinical youth 

development activities to help children and youth acquire protective factors.

5 CII also operates 

child care and Head Start programs for young children. CII’s treatment approach is trauma 

informed, and its services are designed to directly address the impact of trauma on children’s 

lives. An important aspect of CII’s Integrated Service Model is its focus on using evidence-based 

practices in clinical services. Evidence-based practices are highly specified treatment models that 

research has shown to be effective in treating specific symptoms in target populations.

The report’s findings are based on work supported by the Social Innovation Fund (SIF), 

a program of the Corporation for National and Community Service.6 The SIF combines public 

and private resources to increase the impact of innovative, community-based solutions with 

compelling evidence of improving the lives of people in low-income communities. As part of 

the Edna McConnell Clark Foundation SIF project, which focuses on children and youth ages 9 

to 24 years, CII sought to expand its youth services, including the youth development activities 

offered in the Central and South Los Angeles neighborhoods.

Child Trauma and Treatment

While the lifelong impact of childhood mental illness and trauma is well documented, many 

children and youth do not receive the mental health treatment they need. Research has shown 

that many young people in need of such care either do not receive services, or, when they do, 

receive services that are inadequate or ineffective and often unsupported by evidence.

7 This 

report uses the term “usual care” to describe mental health care that is not based on evidence.8

 5

Protective factors are characteristics of individuals, families, or communities that mitigate risks to health 

and well-being. Examples include positive social connections, parenting skills and knowledge of child 

development, and effective communication practices. 6

CII is one of 12 evidence-based programs selected in 2011 to be part of the SIF program. EMCF matched 

$30 million from the SIF program with $30 million from its own endowment. The True North Fund, developed 

by EMCF in 2011, helped the 12 SIF grantees secure the $60 million they were required by statute to raise to 

match this funding. 7

Barbara J. Burns, E. Jane Costello, Adrian Angold, Dan Tweed, Dalene Stangl, Elizabeth M. Z. Farmer, 

and Al Erkanli, “Children’s Mental Health Service Use across Service Sectors,” Health Affairs 14, 3 (1995): 

147-159; Sheryl H. Kataoka, Lily Zhang, and Kenneth B. Wells, “Unmet Need for Mental Health Care among 

(continued)
3 

At the federal level, there has been a significant push to incorporate evidence-based 

practices into mental health care for children and youth. Unlike many other types of mental 

health care, the treatment models for evidence-based practices are well defined. Each model or 

treatment practice typically specifies the target population for which the treatment has been 

shown to be effective, as well as the treatment’s outcomes, content, dosage, and duration. While 

the current trend in the child welfare field is to increase the use of evidence-based practices, not 

every client may be appropriate to receive one of these treatments since they target highly 

specified symptoms or age groups. 

Providing empirically supported treatment in community-based settings presents a host 

of challenges. Community-based settings are often quite different from the university research 

settings where the practices are usually first developed and tested. Community-based providers

typically serve more diverse and higher-risk populations and have larger caseloads. Whether or 

not an evidence-based treatment offered in a community-based setting is effective depends on 

how the provider implements it. In order to transfer efficacy from research to practice, providers 

must implement the treatment with fidelity to the model that was originally tested, which can be

particularly challenging in community-based settings. Fidelity encompasses a number of areas: 

staff training practices, targeting the appropriate population, administering the correct dosage 

and frequency of treatment, and adherence to the prescribed model.

Another challenge to effectively treating children and youth with mental health needs is 

that services are often fragmented and uncoordinated. Available services are often spread across 

different agencies, and funding streams support only specific types of care or treatment. This

fragmentation limits the ability of providers to meet the full range of needs of children and

families, which may include clinical mental health care, services to help the parents or guardians better support their children, and child and youth development activities to help the children 

and youth acquire protective factors and succeed in school.

Overview of CII

CII operates in three of Los Angeles County’s eight Service Planning Areas: Downtown Los 

Angeles, Watts-South Central, and Torrance-Long Beach. Each of these areas is “high need,” 

which means that a significant proportion of adult residents are low income, have not completed 

high school, have poor physical and mental health, and have experienced or reported abuse or

community violence. In these areas, CII strives to implement a neighborhood approach, where-

 

US Children: Variation by Ethnicity and Insurance Status,” American Journal of Psychiatry 159, 9 (2002): 

1548-1555.

8

The term “usual care” refers to treatments that are not empirically supported. Usual care is a term commonly used in the medical field to refer to the treatment received by patients in the control group of a randomized controlled trial.
4 

by CII builds relationships with residents and institutions, such as schools, churches, and other 

child welfare agencies.

CII’s services are roughly divided into four programmatic categories: clinical mental 

health services, family support, child and youth development, and early childhood care and 

education.

•

•

•

•

Clinical mental health services include diagnosis and assessments of mental 

health needs, individual and group therapy, and family therapy. Licensed 

therapists or psychologists typically deliver these services, which may include evidence-based or evidence-informed practices.9

Family support includes programs offered to parents or guardians. These 

programs address parent education, child development, and family economic 

success and stability through case management, parenting classes, support 

groups for fathers and grandparents, financial literacy workshops, and jobreadiness supports.

Youth development includes nonclinical activities, such as programs for 

young people of different ages that address life skills, social skills, literacy 

and education, creative arts, and health and wellness.

Early childhood care and education services are for infants and children 

from birth to 5 years of age. They include Head Start and child care programs. Though early childhood programming encompasses more than onefifth of CII’s overall budget, these services were not the focus of this SIF initiative, which targeted youth ages 9 to 24 years.

As an operating philosophy, CII coordinates the services it provides to meet the holistic 

needs of children and their families. This approach stands in contrast to the fragmented services 

that often characterize the child welfare system. CII conceptualized this philosophy around three 

components: recovery, resiliency, and readiness.

•

•

Recovery from adverse childhood experiences involves reducing the effects 

of trauma and high-risk behaviors. Recovery is the primary focus of CII’s

clinical services.

Resiliency is the capacity of young people and their families to persevere 

and prevent the effects of trauma, and it is developed by enhancing protective 

 9

Evidence-informed practices are treatments that share characteristics with evidence-based practices but 

fall short of the required threshold of evidence.
5 

factors and reducing risks. It is the primary focus of early childhood, family 

support, and youth development programming.

• Readiness for success in school, work, and life involves positive and healthy 

personal behaviors and social relationships, engagement with education or 

occupational training, and the ability to connect to supports or resources. 

CII’s combined services support readiness. 

Through its Integrated Service Model, CII knits these components together to address 

the complex needs of the families it serves. Depending on their needs, clients may receive 

multiple types of services throughout their involvement with CII. The Integrated Service Model 

aims not to simply offer multiple services but to eliminate operating silos among its various 

services and create a system that accurately identifies clients’ full range of needs and ensures

they receive all the support required to address those needs. This report in large part assesses 

CII’s implementation of the Integrated Service Model.

The CII Evaluation

Building evidence is a core component of the SIF, and each SIF grantee is required to undergo 

an evaluation of its service model. The evaluation of CII consisted of two main components: an 

implementation study of CII’s service model and a study of CII’s delivery of evidence-based 

practices, including an in-depth fidelity study of its delivery of Trauma-Focused Cognitive 

Behavioral Therapy (TF-CBT). Both components focused on understanding how the agency 

implements services to address issues of childhood trauma. Overall, this evaluation provided 

CII staff with an independent review of its services, delivery model, and data system. Furthermore, it serves as a case study for other program operators or policymakers in how to structure 

services to meet the holistic needs of clients and how to overcome the barriers to effectively 

serving children associated with a fragmented child welfare system.

The study attempted to answer three main questions:

•

•

•

How do CII’s services and delivery model meet the needs of the diverse 

population it serves, particularly services provided to children and youth 9 to 

24 years old?

How does CII’s Integrated Service Model combine and coordinate its clinical 

and nonclinical services to address the holistic needs of children and families?

How does CII integrate evidence-based practices, particularly Functional 

Family Therapy (FFT) and TF-CBT, into its array of clinical services?
6 

To answer these questions, the MDRC research team analyzed a mix of quantitative and 

qualitative data. The quantitative data included clients’ demographic data and service participation records for services received during 2012 and 2013; the research team collected these data 

from CII’s management information system. The MDRC research team also gathered qualitative data about program operations through interviews with CII staff and representatives from 

some of its partners, primarily during three site visits in 2013. The team also asked CII clinicians and their supervisors to complete a web-based survey in 2013. In partnership with MDRC, 

a team from the Medical University of South Carolina conducted a fidelity study of CII’s 

delivery of TF-CBT services using an observational method. 

Implementation of CII Services

Analyses of these data point to the following findings:

• CII’s Integrated Service Model is innovative and highly ambitious.

CII’s Integrated Service Model seeks to overcome the shortcomings of the child welfare 

system, but CII staff still had to work within that fragmented system to fund its services. CII 

staff confronted numerous external funding constraints to providing services in the holistic way 

envisioned by the Integrated Service Model. CII funds its programs and services through a 

combination of service fees and contracts. However, each of these funding streams comes with 

a host of requirements and stipulations. As a result, the set of services that a client may need 

does not always fit neatly into one of the available funding streams. To tailor services to each 

client’s needs, CII staff must therefore find flexible funding streams or creatively combine 

contractual or other funding streams. 

• Preliminary analysis shows that CII’s implementation of the Integrated 

Service Model appears to be strong with respect to clients receiving clinical services.

CII strives to provide multiple services to clients to address their many needs and highrisk factors. The overwhelming majority of clients receiving CII’s clinical services also participated in another service at CII, and nearly half of clients in clinical services participated in all 

three types of services. It was not possible to fully assess CII’s progress in implementing the 

Integrated Service Model because the research team did not have access to data about clients’ 

risk factors, which are integral to determining whether clients had unmet needs.
7 

• CII is a leader in adopting and implementing evidence-based practices; 

nearly a third of clients receiving clinical services engaged in an evidence-based practice.10

CII also provides a number of evidence-informed therapies; more than 20 percent of 

clients in the analysis received one of these treatments.11 CII is viewed as a leader in implementing and providing evidence-based practices. As an early adopter, CII first began incorporating 

evidence-based practices into its clinical model in 1999. Little is known about national norms 

for usage of evidence-based practices; according to one estimate of youth receiving care 

through California’s county mental health plans, only 2 percent of youth received an evidencebased practice.12 Importantly, evidence-based practices are neither appropriate for every client 

nor are they available for every age group. While the proportion of CII’s clients receiving 

evidence-based practices exceeds the California estimate many times over, it is difficult to know 

whether this concentration of clients receiving these practices was appropriate without knowing 

more about each client’s circumstances. This study, however, was not designed for such an 

analysis, and the research team did not have the detailed data about each client to conduct one. 

• The dosage levels of both FFT and TF-CBT aligned with model expectations.

Analysis of data from CII’s management information system indicated that, on average, 

clients receiving FFT attended 15 sessions over the course of five months. Similarly, clients 

receiving TF-CBT on average attended 19 sessions over five months. The dosage of both 

therapies fell within the bounds set by their respective treatment models, although both fell on 

the higher end of the models’ acceptable ranges.

13 Data were not available on factors that may 

have contributed to the relatively high number of sessions; however, CII staff indicated in 

interviews that the complex nature of the clients’ history of trauma and tumultuous lives often

resulted in frequent family crises during treatment.

 10Evidence-based practices include the following treatments and programs: Cognitive Behavioral Intervention for Trauma in Schools, Child Parent Psychotherapy, FFT, Incredible Years, Managing and Adapting 

Practice, Multidimensional Treatment Foster Care, Parent-Child Interactive Therapy, Reflective Parenting 

Program, TF-CBT, and Trauma Systems Therapy-Substance Abuse. 11Evidence-informed practices include the following treatments and programs: Domestic Violence Treatment Groups, Project Fatherhood, Wraparound services, Youth with Sexual Behavior Problems, and social 

skills and parent support groups. These practices are informed by some evidence but not as much as evidencebased practices have accumulated. 12Technical Assistance Collaborative and Human Services Research Institute, California Mental Health 

and Substance Use System Needs Assessment Appendices (California Department of Health Care Services, 

2012). Website: www.dhcs.ca.gov/provgovpart/Documents/Data%20Appendices%203%201%2012.pdf. 13The acceptable range for FFT is 8 to 12 sessions; the acceptable range for TF-CBT is 12 to 20 sessions.
8 

• CII’s fidelity to the TF-CBT model was in line with previous fidelity 

studies of TF-CBT in community-based settings. Clients on average 

were more than 50 percent likely to receive half of the treatment’s core 

components.

A rigorous examination of the adherence of therapists at CII to the TF-CBT model using an observational method found that the average client had at least a 50 percent chance of 

receiving half of the core components of the model.14 The finding that clients did not receive all 

components of TF-CBT is consistent with other research on the implementation of TF-CBT in 

community-based settings. Clients were most likely to receive the cognitive coping, relaxation, 

affective expression and modulation, psychoeducation, and trauma narrative components of TFCBT. The study found therapists delivered the parent component at low rates, which is also 

consistent with prior research.15 The study found that fidelity varied at the client level rather 

than the therapist level, indicating that clients seen by the same therapist could have had varying 

experiences with TF-CBT.

The fidelity study also found that a therapist self-report tool, the Brief Practice Checklist, led to similar conclusions about the usage of TF-CBT components as did an observational 

method. This finding indicates that the Brief Practice Checklist may be a promising low-cost 

tool to monitor fidelity. Observational methods of monitoring fidelity, such as the one used in 

this study, are time and resource intensive and not practical on a large scale for many community-based organizations. Therapists and supervisors could use the Brief Practice Checklist to 

monitor whether or not therapists are delivering the TF-CBT components, and supervisors 

could use the information in the checklist to advise therapists on cases and on how to eliminate 

any roadblocks to providing the treatment as intended. Organizations could also use data from 

the checklists to compare differing outcomes among cases and identify and assess any patterns. 

However, there are some limitations to using the checklist on its own to evaluate fidelity. 

Therapists in this study had the tendency to over-report their use of components, relative to the 

observational data. Additionally, observational methods can measure the extent to which 

therapists implement each component, whereas the Brief Practice Checklist can only measure 

whether or not therapists implement the components. However, organizations could use the 

Brief Practice Checklist in combination with others tools, such as periodic direct or audiorecorded observations, to monitor fidelity more comprehensively. The use of the Brief Practice 

Checklist as a fidelity tool merits further study. 

 14A Technical Resource for this report presents the full study and is available on the MDRC website at 

www.mdrc.org. 15TF-CBT requires that the therapist meet separately with the child and the parent or guardian with similar 

frequency, and meet conjointly with both at particular points during treatment.
9 

Conclusion

As policymakers, practitioners, and researchers in the child welfare field work to improve 

services available through the child welfare system, CII and its experience developing and 

implementing its Integrated Service Model as well as delivering evidence-based practices offer 

important lessons. These lessons could be useful not only to similar multiservice organizations 

but to all those in the child welfare field looking for the best ways to serve children through an 

often fragmented child welfare system. Those interested in evidence-based practices may find 

the findings from the fidelity study of TF-CBT useful. These findings suggest that one area for 

further research could be investigating how to cost-effectively combine self-reporting tools and 

observational methods to support fidelity.
About MDRC

MDRC is a nonprofit, nonpartisan social and education policy research organization dedicated 

to learning what works to improve the well-being of low-income people. Through its research 

and the active communication of its findings, MDRC seeks to enhance the effectiveness of social and education policies and programs.

Founded in 1974 and located in New York City and Oakland, California, MDRC is best known 

for mounting rigorous, large-scale, real-world tests of new and existing policies and programs. 

Its projects are a mix of demonstrations (field tests of promising new program approaches) and 

evaluations of ongoing government and community initiatives. MDRC’s staff bring an unusual 

combination of research and organizational experience to their work, providing expertise on the 

latest in qualitative and quantitative methods and on program design, development, implementation, and management. MDRC seeks to learn not just whether a program is effective but also 

how and why the program’s effects occur. In addition, it tries to place each project’s findings in 

the broader context of related research — in order to build knowledge about what works across 

the social and education policy fields. MDRC’s findings, lessons, and best practices are proactively shared with a broad audience in the policy and practitioner community as well as with the 

general public and the media.

Over the years, MDRC has brought its unique approach to an ever-growing range of policy areas and target populations. Once known primarily for evaluations of state welfare-to-work programs, today MDRC is also studying public school reforms, employment programs for exoffenders and people with disabilities, and programs to help low-income students succeed in 

college. MDRC’s projects are organized into five areas:

•

•

•

•

•

Promoting Family Well-Being and Children’s Development

Improving Public Education

Raising Academic Achievement and Persistence in College

Supporting Low-Wage Workers and Communities

Overcoming Barriers to Employment

Working in almost every state, all of the nation’s largest cities, and Canada and the United 

Kingdom, MDRC conducts its projects in partnership with national, state, and local governments, public school systems, community organizations, and numerous private philanthropies.