Discovering and disseminating effective methods to improve the quality of available treatment services for adolescent externalizing problems is an urgent public health priority. Despite the strong legislative and policy focus on quality of care evident in the CHIP Reauthorization Act of 2009 and the Affordable Care Act of 2010, comprehensive reports underscore the enduring "quality chasm" between behavioral treatments proven in controlled research versus those commonly practiced in usual care. The quality gap is highly evident for adolescent externalizing problems (AEPs), which encompass serious conduct problems, delinquency, and substance misuse. AEPs are the most common adolescent behavioral issues in specialty care, which follows from high prevalence rates: conduct disorder has a 9.5% lifetime prevalence rate, and 19% of adolescents report past-year illicit drug use with 7% meeting criteria for psychiatric disorder. Yet standard treatment quality for AEPs is considered mediocre to inadequate due to a host of factors headlined by the absence or modest quality of evidence-based services, insufficient provider training, and little quality monitoring.

Two behavioral treatment approaches are prime candidates for upgrading the quality of AEP treatment services. Both family therapy (FT) and cognitive-behavioral therapy (CBT) have excellent efficacy evidence for AEPs in both research and community settings. Each has strong support for treating serious conduct problems, delinquency, and substance use, and each has several manualized versions proven efficacious across the AEP range. Due to this extensive evidence base, there is incentive from clinical providers and payers to deliver these approaches in routine care: Both are now approved for treating AEPs by federal and private insurance plans and by regulatory agencies that govern licensed treatment providers. Notably, therapists report that both approaches are highly valued in everyday practice.

By consensus, the most efficient pathway toward improving the quality of mental health services is to increase the adoption and delivery of evidence-based interventions (EBIs) in usual care. However, there is a caveat: For EBIs to be effective in frontline settings, they must be delivered with sufficient fidelity to the principles and procedures of the approaches they represent. This remains a most difficult challenge for which innovative solutions are sorely needed. With regard to AEPs, controlled studies have shown that strong fidelity to the FT and CBT approaches predicts improved client outcomes in both efficacy and effectiveness studies. Yet, at this time, neither FT nor CBT are widely implemented with fidelity in community clinics that treat AEPs. To promote EBI fidelity as a core virtue of the behavioral care system, the study team published a theoretical model in which EBI implementation is recognized as an essential driver of positive client outcomes. This model includes structural characteristics of care that directly influence both implementation and outcomes, as well as outcomes considered relevant within the "quality of care" framework. The middle section depicts elements of implementation that have proven salient for effective EBI delivery, including technical factors (adherence to core treatment techniques, therapist competence) and relational factors (e.g., alliance), given that both are related to outcomes. According to this model and similar others, EBI implementation fidelity is a multidimensional construct with three primary facets: Adherence (extent to which signature EBI techniques are utilized), Competence (skillfulness and responsiveness of EBI delivery), and Alliance (working relationship between provider and client). In AEP research, fidelity-outcome studies consistently find that stronger EBI adherence and stronger alliance predict better client outcomes. Evidence for competence-outcome effects is less consistent, in large part because competence remains difficult to operationalize reliably. According to this framework, innovations aimed at improving service quality should directly target EBI fidelity; stronger EBI fidelity will then boost client outcome.