3 - (IOP 4) Fidelity to TF-CBT and Child PTSD Outcomes: A Multi-site Community Mental Health Trial

Background: Evidence-based treatment (EBT) fidelity has been identified as an important mechanism for achieving desired clinical outcomes; however, studies have yielded mixed findings on its relation to clinical improvements, often due to methodological limitations. Research is needed that investigates fidelity using rigorous, validated measures with diverse populations in usual care settings. This is particularly true for trauma-focused EBTs. Despite the hypothesized importance of key intervention components, such as exposure, relations between fidelity and outcomes of trauma-focused EBTs have been relatively understudied compared to other EBTs.

Methods: We present outcomes of a randomized trial of supervision strategies to support trauma-focused cognitive behavioral therapy (TF-CBT) implementation in community mental health centers (CMHCs). The trial compared the effects of two supervision techniques (i.e., symptom and fidelity monitoring [SFM] v. SFM + behavioral rehearsals) with supervision-as-usual. One aspect of TF-CBT fidelity—adherence—was examined on randomly selected treatment sessions using the Therapeutic Process Observational Coding System for Child Psychotherapy-Strategies Scale. Adherence describes the degree to which a clinician employs the prescribed EBT components. Youth (ages 6-17) and their guardians reported on clinical outcomes via the UCLA Post Traumatic Stress Disorder Reaction Index. We examined changes in youth- and guardian-reported posttraumatic stress (PTS) symptoms from baseline to 3- and 6-month follow-up using two-level hierarchical generalized linear models. We subsequently examined associations between adherence to each TF-CBT component and changes in symptoms using separate two-level hierarchical generalized linear models. Benjamin-Hochberg corrections were used to adjust for multiple testing.

Results: Forty-eight supervisors and 151 clinicians from 39 different CMHCs participated. Clinical outcomes data was available for 268 youth participants. Participating youth were mostly female (69.9%) and comprised of diverse racial backgrounds. Most (71.7%) of the sample was white, and 21.6% identified as multiracial. Approximately one quarter (22.7%) of the sample identified as Hispanic or Latino. Across study conditions, youth (ß = -1.31, 95% CI: -1.82, -0.79, p < .001) and guardians (ß = -1.75, 95% CI: -2.26, -1.24, p < .001) reported significant reductions in PTS symptoms. When controlling for baseline PTS symptom severity and supervision condition, greater extensiveness of trauma narrative delivery was associated with greater reductions in youth-reported PTS symptoms (ß = -0.33, p< 0.05). No associations between other TF-CBT components and clinical outcomes were found (all p>0.05).

Conclusions: Findings revealed a significant relationship between fidelity to TF-CBT’s exposure-based component and improved clinical outcomes. Given the diverse racial and ethnic composition of the sample, further research is warranted to explore whether fidelity-driven treatment effects vary across demographic groups. These findings inform efforts to optimize TF-CBT implementation and supervision strategies, ultimately improving access to high-quality trauma-focused care in community settings.