Improving Quality of Care in Child Mental Health Service Settings

Study Overview
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Brief Summary
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The investigators recently completed an NIMH R34 in which they piloted a patient- and provider-informed tablet-based toolkit designed to facilitate delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - a treatment that was selected because it addresses a wide range of symptoms using techniques shared by other treatments for emotional and behavioral disorders. The tablet-based toolkit consists of numerous components (e.g., videos, interactive games, drawing applications) that are designed to facilitate provider-patient interactions in a way that enhances children's engagement and supports adherence to the treatment model. The tablet-based toolkit was very well received by children, caregivers, and providers in the pilot evaluation. Moreover, all benchmarks for feasibility were met or exceeded. This study proposes to conduct a hybrid effectiveness-implementation trial to examine the extent to which the tablet intervention may improve fidelity, engagement, and children's mental health outcomes. The investigators will conduct a randomized controlled trial with 120 mental health providers and 360 families in partnership with dozens of clinics in the Carolinas and Florida. Providers will be assigned randomly to tablet-facilitated vs. standard TF-CBT. Youth aged 8-16 years with clinically elevated symptoms of PTSD will be recruited. Baseline and 3-, 6-, 9-, and 12-month post-baseline assessments will be conducted by independent, blind evaluators. Sessions will be videorecorded for observational coding of engagement and fidelity by independent raters blind to study hypotheses. The investigators will also examine costs and conduct semi-structured interviews with families, providers, supervisors, and agency leaders to inform future dissemination and implementation initiatives. Technology-based resources that are scalable, easy to use, and designed for efficient integration into everyday practice may have sustained national impact.

Detailed Description
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Assuring children access to the highest quality mental health care is a top national priority. Yet, quality of care continues to be highly variable in traditional service settings. Novel, scalable solutions are needed to address modifiable quality-of-care indicators in sustainable ways. To this end, provider fidelity and children's engagement are key correlates of clinical outcome and practical targets for intervention. There is tremendous opportunity to address both through technology. Studies in child education show that interactive games, touch-screen learning, and demonstration videos enhance engagement, knowledge, motivation, and learning. These benefits also may extend to the therapeutic context, where strategic integration of technology-based activities may enhance children's learning, strengthen the therapeutic alliance, and keep providers on protocol. The investigators recently completed an NIMH R34 in which they piloted a patient- and provider-informed tablet-based toolkit designed to facilitate delivery of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - a treatment that was selected because it addresses a wide range of symptoms using techniques shared by other treatments for emotional and behavioral disorders. The tablet-based toolkit consists of numerous components (e.g., videos, interactive games, drawing applications) that are designed to facilitate provider-patient interactions in a way that enhances children's engagement and supports adherence to the treatment model. The tablet-based toolkit was very well received by children, caregivers, and providers in the picot evaluation and all benchmarks for feasibility were met or exceeded. The investigators propose to conduct a hybrid effectiveness-implementation trial to examine the extent to which the tablet intervention may improve fidelity, engagement, and children's mental health outcomes. The investigators will conduct a randomized controlled trial with 120 mental health providers and 360 families in partnership with dozens of clinics in the Carolinas and Florida. Providers will be assigned randomly to tablet-facilitated vs. standard TF-CBT. Youth aged 8-16 years with clinically elevated symptoms of PTSD will be recruited. Baseline and 3-, 6-, 9-, and 12-month post-baseline assessments will be conducted by independent, blind evaluators. Sessions will be videorecorded for observational coding of engagement and fidelity by independent raters blind to study hypotheses. The investigators will also examine costs and conduct semi-structured interviews with families, providers, supervisors, and agency leaders to inform future dissemination and implementation initiatives. Technology-based resources that are scalable, easy to use, and designed for efficient integration into everyday practice may have sustained national impact.

Official Title
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Improving Quality of Care in Child Mental Health Service Settings

Conditions
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Post Traumatic Stress Disorder, Technology, Child Abuse

Intervention / Treatment
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* Behavioral: TFCBT
* Behavioral: eTFCBT


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: victim of at least one potentially traumatic event (e.g. sexual/physical assault, witnessed violence, disaster, serious accident) have at least one symptom on each PTSD symptom cluster (re-experiencing, avoidance, hyperarousal) Exclusion Criteria: exhibits psychotic symptoms (active hallucinations, delusions, impaired thought processes) by caregiver or child significant cognitive disabilities, developmental delays, or pervasive developmental disorder active suicidal or homicidal ideations no consistent caregiver available to participate

Ages Eligible for Study
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Minimum Age: 8 Years
Maximum Age: 16 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Treatment as usual<br>Trauma Focused Cognitive Behavioral Therapy | Behavioral: TFCBT<br>* treatment as usual<br>|
| Experimental: Tablet-Facilitated TF-CBT<br>Standard treatment with the addition of in-treatment/session iPad activities | Behavioral: eTFCBT<br>* tablet-facilitated Trauma Focused Cognitive Behavioral Therapy (eTFCBT)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Child Involvement Ratings Scale | Child engagement will be measured via coding of audiotaped sessions by independent, trained raters who are blind to study purpose and hypotheses. The Child Involvement Ratings Scale (CIRS), a 6-item scale that measures child engagement for each session, will be used. Four positive involvement items and two negative involvement items are rated for each session on a 6-point scale (not at all to a great deal present). The positive-involvement items emphasize the extent to which children initiate discussions, demonstrate enthusiasm, self-disclose, and demonstrate understanding. Negative-involvement items address withdrawal or avoidance in treatment. Coders provide ratings based on two 10-min segments of session audiotapes (beginning at min 10 and min 40). | will be assessed throughout the course of treatment (expected to be 12-20 weeks in duration for each participant) | 
| Provider Treatment Fidelity | Fidelity to the TF-CBT protocol will be measured via coding of videotaped treatment sessions by independent, trained raters who are blind to study purpose and hypotheses. Ratings will be completed using the TF-CBT Version of the Therapy Process Observational Coding System for Child Psychotherapy (TF-CBT TPOCS-S), a behaviorally specific checklist of TF-CBT provider behavior that we have modified for the current study to ensure relevance to the eTF-CBT condition. This checklist will be used to calculate providers' fidelity to each TF-CBT component. Two independent raters will listen to video-recorded treatment session tapes and complete the TF-CBT TPOCS-S to code the presence/absence of specific treatment techniques depicted on the tapes. | will be assessed throughout the course of treatment; an expected duration of 12-20 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Center for Epidemiological Studies Depression Scale for Children (CES-DC) | assesses the severity of depressive symptomatology in children. It is a 20-item self-report measure with possible scores ranging from 0-60. Scores over 15 are indicative of significant levels of depressive symptoms. | baseline, 3, 6, 9, 12 months post baseline | 
| Therapeutic Alliance Scale for Children (TASC) | The TASC is an 8-item measure of the child's alliance with the therapist using a 4-pt scale. It has good internal consistency and interrater reliability. | baseline, 3, 6, 9, 12 months post baseline | 
| Child/Adolescent Satisfaction Questionnaire (CASQ). | The CASQ is a 15-item instrument that assesses child satisfaction with mental health treatment. | baseline, 3, 6, 9, 12 months post baseline | 
| The Shame Measure | 4-item instrument that assesses feelings of shame following abuse. | baseline, 3, 6, 9, 12 months post baseline | 
| The Child and Adolescent Trauma Screen (CATS) - Youth Version | 35-item instrument that assesses exposure to traumatic events and all 20 DSM-V symptoms of PTSD. | baseline, 3, 6, 9, 12 months post baseline | 
| Caregiver Satisfaction Questionnaire (CSQ) | The CSQ is a 15-item instrument that assesses caregiver satisfaction with mental health treatment. | baseline, 3, 6, 9, 12 months post baseline | 
| Working Alliance Inventory (WAI-short form) | The WAI is a 12-item measure of the parent-therapist alliance using a 7-point scale (never to always). | baseline, 3, 6, 9, 12 months post baseline | 
| Brief Problems Monitor (BPM) | The BPM is a 19-item measure of emotional and behavioral functioning in children. The BPM is well-validated and comparable to the lengthier Child Behavior Checklist. | baseline, 3, 6, 9, 12 months post baseline | 
| Center for Epidemiologic Studies Depression Scale (CESD-R). | The CESD-R is a 20-item self-report scale of depression. It is widely used and demonstrates excellent psychometric properties. | baseline, 3, 6, 9, 12 months post baseline | 
| The Child and Adolescent Trauma Screen (CATS) - Caregiver Version | 35-item parent version of the CATS-Youth. | baseline, 3, 6, 9, 12 months post baseline | 
| The Alabama Parenting Questionnaire | 42-item measure to assess parenting practices. | baseline, 3, 6, 9, 12 months post baseline | 
| The Kessler 6 | widely used 6-item measure of general distress that is well-validated. | baseline, 3, 6, 9, 12 months post baseline | 
| Evidence-Based Practice Attitude Scale (EBPAS) | 15 items, assessing providers' perceptions of appeal of EBT, openness to innovation, perceived divergence with usual care (alphas .59-.90; M=.77). | baseline, post baseline | 
| Knowledge of Behavioral Principles as Applied to Children | assess understanding of the application of behavioral principles to youth. Internal consistency=.42-.84; sensitivity to change. | baseline, post baseline | 
| Acceptability, Appropriateness and Feasibility Measure ( | 12-item measure to monitor and evaluate implementation efforts. This measure has been shown to have solid psychometric properties. | baseline, post baseline | 
| Computer Assisted Therapy Attitudes Scale | 8-item measure design to assess attitudes toward computer use in treatment. | baseline, post baseline | 
| Organizational Readiness for Implementing Change | 12-item measure designed to assess an organization's readiness to implement new policies, programs, and practices. | baseline, post baseline | 
| TF-CBT Organizational Support Measure | 19-item instrument to assess a community mental health organization's activities related to the delivery of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). | baseline, post baseline | 
| Burnout Measure | screener that assesses providers' feelings about their work, and their perceptions of how their co-workers feel about the work they do. | baseline, post baseline |