The trajectory of fidelity in a multiyear trial of the family check-up predicts change in child problem behavior.

Establishing the fidelity with which an intervention is delivered is a critical dimension of understanding intervention effects in both efficacy and effectiveness trials (McHugh & Barlow, 2010). Fidelity is typically comprised of two key components: adherence (the extent to which specific procedures were delivered) and competence (the level of skill demonstrated). Parent training interventions are a well-established approach for the prevention and treatment of child and adolescent behavior problems (e.g., Lundahl, Risser, & Lovejoy, 2006) and community implementation is a high priority (National Research Council and Institute of Medicine, 2009). Although fidelity to parent training programs has been consistently associated with clinically meaningful child and parent-level outcomes (e.g., Forgatch, Patterson, & DeGarmo, 2005; Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Hogue et al., 2008; Ogden, Hagen, Askeland, & Christensen, 2009; Smith, Dishion, Shaw, & Wilson, 2013), few studies have evaluated fidelity to evidence-based parenting programs with the same families longitudinally. The notable exception is a series of studies concerning implementation of Parent Management Training–Oregon Model (PMTO). Forgatch and DeGarmo (2011) evaluated ratings from three time points during training in PMTO and found that fidelity increased and became less variable over time, and that fidelity was sustained across three generations of therapists trained in PMTO as part of a large-scale implementation effort in Norway. Also, Forgatch and colleagues (2005) and Hukkelberg and Ogden (2013) found, in studies from two separate trials of PMTO, that higher fidelity, assessed at three time points, predicted significant reductions in parent-reported child behavior problems. The Family Check-Up The Family Check-Up (FCU) is a brief, individually-tailored intervention intended to motivate use of effective parenting skills to improve youth adjustment. The FCU comprises three meetings: initial contact, ecological assessment, and feedback. Feedback to caregivers emphasizes family strengths, yet draws attention to possible areas of change. Findings from the Early Steps multisite randomized trial indicate that families assigned to the FCU condition experience reductions in youth problem behaviors during preschool (e.g., Dishion et al., 2008) and at at school age (e.g., Dishion et al., 2014). The Early Steps trial was delivered using a health maintenance framework consisting of offering the FCU to families in the intervention condition each year beginning at age 2. The COACH rating system (Dishion, Knutson, Brauer, Gill, & Risso, 2010) was developed to assess competent adherence to the FCU feedback session and is based on Forgatch and colleagues’ work with the PMTO model. Smith and colleagues (2013) examined fidelity to the FCU in a subsample of families from this trial who rated the child in the clinical range for behavior problems at age 2. Greater fidelity to the FCU at age 2 was related to improvements in parent-reported problem behaviors two years later (age 4). This effect was mediated by ratings of observed in-session caregiver engagement in the FCU at age 2 and improvements in observed positive parenting behaviors, assessed at age 3. The Current Study An important component to understanding therapist fidelity to interventions administered to the same families over time is the evaluation of drift; that is, changes in the delivery of the intervention over time. The health maintenance framework of the Early Steps trial provides a unique opportunity to examine the effect of drift as related to outcomes at the family level. Our aims were twofold: (1) evaluate drift in fidelity to the FCU across the first four years of a multisite randomized efficacy trial (child ages 2–5) and (2) examine the effect of drift in fidelity on changes in child oppositional and aggressive behaviors at ages 7.5 and 8.5. We hypothesized that the trajectory of fidelity would be related to intervention outcomes for families with children rated in the clinical range for behavior problems at study entry. We followed the same 79-family clinical subsample from the study by Smith et al. (2013). We applied latent growth modeling with covariates that could account for drift (changing therapist, study site, caregiver depression, income, baseline child noncompliance).