a statewide training of community clinicians to treat ... · youths who have been traumatized,...

CLINICIANTRAININGFORTRAUMATIZEDYOUTHS 1

AStatewideTrainingofCommunityClinicianstoTreatTraumatizedYouthsInvolved

withChildWelfare

DeviMiron&MichaelS.Scheeringa

TulaneUniversitySchoolofMedicine

AuthorNote

DeviMiron,DepartmentofPsychiatryandBehavioralSciences,TulaneUniversity

SchoolofMedicine;MichaelS.Scheeringa,DepartmentofPsychiatryandBehavioral

Sciences,TulaneUniversitySchoolofMedicine

ThisresearchwassupportedbytheAdministrationforChildrenandFamilies,

90C01105.

WewouldliketoacknowledgeCamilaWoodmanseeandAlyssaSingerfortheir

contributionstothisproject.

CorrespondenceconcerningthisarticleshouldbeaddressedtoDeviMiron,

DepartmentofPsychiatryandBehavioralSciences,TulaneUniversitySchoolofMedicine,

1430TulaneAve.,#8055,NewOrleans,LA70112.E-mail:[email protected]


Abstract

Despiteconsiderableinvestmentineffortstodisseminateevidence-basedtreatments

(EBTs),fewdataareavailableonhowfrequentlycliniciansachievecompetencein

deliveringthetreatmentsoronwhetherclinicaloutcomesactuallyimprove.TheLouisiana

ChildWelfareTraumaProject(LCTP)wasafive-yeardemonstrationprojectfundedbythe

Children’sBureau.OneoftheaimsoftheLCTPwastotraincommunityclinicians

statewideinanEBTforposttraumaticstressdisorder(PTSD).Atrainingmodelwas

designedtoreachanywillingcommunitypractitionerwithminimaltravel,cost,andtime

involvedfortraineesandtrainer.Ofthe335clinicianswhoattendedaone-daytrainingin

YouthPTSDTreatment(YPT;Scheeringa&Weems,2014),amanualizedtreatmentfor

youthswithPTSD,117beganconsultationcalls.Forty-five(38%)clinicianswhobegan

callsachievedAdvancedtraining,completingatleastonecaseusingYPTandattending

weeklycalls.Ofthe102clientsdiscussedduringcalls,64(63%)completedYPT.Pre-and

post-treatmentmeasureswereavailablefor17(27%)ofthecompleters.All17clients

showeddecreasesintheirPTSDsymptomsbyyouthorcaregiverreport;with12(71%)

showingadecreaseinsymptomcountbyatleasthalfofthepre-treatmentscore.Thisis

thefirstknownreportoftheproportionofcommunityclinicianswhovoluntarily

completedconsultationcallstoachievecompetencefollowinginitialtraininginanEBT.

TheresultssuggestthateffectivenessofanEBTispossibleincommunitysettingsbutis

likelyconstrainedbycliniciansbeingwillingand/orabletocompletetraining

requirementsgearedtowardsachievingcompetencyinandfidelitytotheprotocol.

Becausethemajorityofcliniciansdidnotcompletetrainingrequirements,thissuggests

majorlimitationsinthecurrentmodelsofdissemination.


Keywords:childwelfare;evidence-basedtreatmentdissemination;PTSDtreatment


Childreninvolvedinthechildwelfaresystemoftenhavebeenexposedtopotentially

traumaticevents,includingphysicalabuse,sexualabuse,andexposuretodomestic

violence(Griffinetal.,2011;Kolkoetal.,2010).Followingtraumaticexperiences,these

youthsmaydeveloppsychiatricproblemssuchasposttraumaticstressdisorder(PTSD)

andotherdisordersincludingoppositionaldefiantdisorder,separationanxietydisorder,

attention-deficit/hyperactivitydisorder,andmajordepressivedisorder(DeYoung,

Kenardy,Cobham,&Kimble,2012;Scheeringa&Zeanah,2008;Scheeringa,Zeanah,Myers,

&Putnam,2003).Studieshaveconsistentlydemonstratedsignificantassociationsamong

traumaticandotheradverseexperiences,theonsetofparent-childrelationship

disturbances(e.g.,Lieberman,2004;Lieberman&Knorr,2007),andlaterdiagnosisof

psychiatricandsubstanceabusedisorders(Greenetal.,2010).Childrenexperiencing

traumaalsomayhavetroubleformingtrustingrelationshipswithfamilymembersand

otherscaringforthem,peers,andsiblings.

Giventheprevalenceofexposuretopotentiallytraumaticeventsinthechildwelfare

system,recentlytherehavebeeneffortstodevelopbestpracticesandimprovetrauma-

informedcareservices(Conradi,Wherry,&Kisiel,2011;Murphy,Moore,Redd,&Malm,

2017;Samuels,2011;Strand&Sprang,2018).Theseeffortshavegenerallyembracedthe

SubstanceAbuseandMentalHealthServicesAdministration’s(2015)conceptofatrauma-

informedsystemthatrealizesthewidespreadimpactoftrauma,recognizesthesignsand

symptomsoftrauma,andintegratesknowledgeabouttraumaintopolicies,proceduresand

practices.

Althoughthereisnoconsensusontheessentialcomponentsofatrauma-informed

childwelfaresystem,theNationalChildTraumaticStressNetwork(NCTSN)outlinesthata


comprehensivetrauma-informedchildandfamilyservicesystemincludesscreening,

evidence-basedtreatment,resourceavailability,resilience-building,addressingcaregiver

trauma,continuityofcareandcollaboration,careforstaff,andrespondingtotheunique

needsofdiversecommunities.TheNCTSN(2013)hasdevelopedtrainingmaterialsfor

childwelfarestafftoincreasetheirknowledgeoftraumaandimproveresponsivenessto

youthswhohavebeentraumatized,knownastheChildWelfareTraumaTrainingToolkit.

TheChildren’sBureau,anagencywithintheAdministrationforChildrenandFamilies,has

fundedaseriesofdemonstrationprojectstoimprovethecapacityofchildwelfaresystems

torespondtotheneedsoftraumatizedchildren(Samuels,2013).Althoughresultsarestill

pending,theseeffortsmayassistjurisdictionsinrespondingtofederallegislationthat

officiallyrecognizestheprevalenceandimpactoftraumaonchildreninvolvedwiththe

childwelfaresystemandrequiressystemstoscreenandreferforappropriatecare(Child

andFamilyServicesImprovementandInnovationAct,2011).

Inthispaper,wedescribeoneoftheserecentprojects,aimedatenhancingthe

capacityofachildwelfaresystemtoaddressPTSDamongtheyouththeyservewith

evidence-basedtreatment(EBT).EstimatesofyouthswithPTSDinthechildwelfare

systemrangefrom19%forchildrenwhoareplacedinfostercare(Kolkoetal.,2010)to

25%foradultswhohadresidedinfostercareaschildren(Pecoraetal.,2005).Theseare

significantproportionsnotwithstandingthenumberofchildrenwhohavesymptomsbut

whodonotmeetfullcriteriaforPTSDandmayalsobenefitfromEBTforPTSD.

Despitetheneed,childwelfaresystemsoftenhavelimitedcapacitytorespond

effectivelybecausetheyaredependentonpublicfunds(e.g.,Medicaidorotherfederaland

stateprograms)topayforservicesandmanyprovidersareunwillingtoacceptthe


relativelylowreimbursementratesoffered.Inaddition,somecliniciansavoidworking

withyouthinvolvedinthechildwelfaresystemduetothedocumentationandpossible

courttestimonyrequired.Further,practitionertrainingandexperienceinevidence-based

treatmentstosufficientlyaddresstheneedsoftraumatizedyoutharelacking(Hansonet

al.,2014).

Overthelasttwodecades,therehasbeenacallforclinicianstocompletetrainingin

anddeliverevidence-basedtreatments(EBTs)foremotionalandbehavioralproblems

(McHugh&Barlow,2010;Novins,Green,Legha,&Aarons,2013).Over500EBTsexistfor

childandadolescentmentalhealthdisorders(Dorsey,Berliner,Lyons,Pullman,&Murray,

2016),andextensivedisseminationprojectshavebeenconductedwithenormousfinancial

supportfromnationalandstategovernmentsandprivatefundingsources.Itisnotclear

howeverthatdisseminationprojectshavemetthegoalsofimprovingclientoutcomes

whenextendingbeyondthetightlycontrolledenvironsofrandomizedtrialsandmoving

intouncontrolledcommunity-widedisseminations.

Beforeclientoutcomescanimprove,communityclinicianshavetoadopttheEBTs.

InareviewofthemajorinitiativestodisseminateandimplementEBTs,McHughand

Barlow(2010)notedthatfewdisseminationinitiativesrecordedinformationonthetwo

mostbasicoutcomesrequiredtojustifythemagnitudeoffundingandeffortspent:(1)

numberofclinicianswhofailedtoreachcompetency,and(2)clientsymptomoutcomes.

Withoutsuchbasicmetrics,examinationscannotbegintoexploremediatorsofsuccessful

adoption,suchasdurationofconsultation,thebestsustainabilitymodels(i.e.,“trainthe

trainer”),stakeholdersupportfacilitators,orwaystoaddressthehighlyvariableratesat

whichcliniciansadoptEBTsfortreatingPTSD(Rosenetal.,2015).


InareviewofdisseminationeffortsBarlow,Bullis,Comer,&Ametaj(2013)

concludedthat“didactictrainingsaloneareinsufficient”(p.19),andtherenowseemstobe

broadconsensusaboutthat.Thedifferenttrainingstrategiesthatprojectshaveusedto

movebeyond“didactictrainingsalone”havebeenvaried[seeCohen&Mannarino,2008,

forareviewofeffortstodisseminatetrauma-focusedcognitivebehavioraltherapy(TF-

CBT)incommunitysettings].Nearlyallofthedifferenttrainingstrategieshaveincluded

ongoingconsultationsforsixto12months,whilethedetailsoffrequency(weeklyversus

lessoften),groupsize,format(in-personversusremote),andexpectationsofparticipation

intheconsultationsvary.Differentrecruitmentstrategieshaverangedfromtrainingany

willingcommunityclinician(Dorseyetal.,2016)tohiringdedicatedprojectclinicians

(Murray,2017).

Disseminationstudiesareonlybeginningtoincludeinformationontraining

requirementsandcompletionrates.Dorseyetal.(2016)describetheWashingtonState

DepartmentofSocialandHealthServicessponsoredtrainingforCBT+(Chorpita,Taylor,

Francis,Moffitt,&Austin,2004;Weiszetal.,2012).Thistrainingincludedathree-dayin-

persontrainingforwhichcliniciansreceived18to20continuingeducationcredits,

followedbysixmonthsofbiweeklyconsultationcallswith10to15traineespercall.

Traineeswereexpectedtoattendnineto12callstoreceiveacertificateofcompletion.The

numberofcliniciansoriginallyinvitedforthetrainingwasnotreportedbutinfourcohorts

oftraineesoverthreeyears,therewere400participantsincludingnon-clinicians(e.g.,

administrators,caseworkers,orotherstaff).Thetotalnumberofcliniciansand

supervisorscompletingthepre-trainingsurveywas284and180completedapost-

consultationfollow-upsurvey.Callattendancedatawereavailableforonly155


participants.Themeannumberofcallsattendedwas9.4(SD1.9,range1-12),with80%of

the155(n=124)attendingnineormorecalls.However,neitherthepercentageoftotal

availablecliniciansstatewidenorthepercentageofclinicianswhobegantrainingand

completedtrainingexpectationswasreported.

Giventheneedfortrauma-informedservicesforyouthinvolvedwithchildwelfare

andthegapintheextantliteratureregardingEBTtrainingcompletionratesandclient

outcomes,inthisstudywereportdataaddressingtworesearchquestions.First,what

percentagesofcommunityclinicianswhoareinvitedtofree,low-burdentrainingsaimedat

enhancingtheservicearrayforthechildwelfarepopulationwillengagetoachievethree

differentlevelsofcompetency–aminimumlevelofattendanceataone-daytrainingonly,a

basiclevelthatincludedfollow-upphoneconsultationsthatdidnotinvolvetheirown

cases,oranadvancedlevelofcompetencythatincludedfollow-upphoneconsultationsthat

involvedtheirowncasesforthreetosixmonths?Therearenoknownpriorestimatesin

theliteratureofthepercentageofclinicianswhovoluntarilyinitiatedanEBTtrainingand

followedthroughtoachievetrainingexpectations.Intheabsenceofanempirically-derived

parameterweaimedforthebenchmarksuggestedbyDorseyetal.(2016)of80%of

clinicianstocompletetrainingexpectationsandachievetheadvancedlevelofcompetency.

Oursecondresearchquestionwas,whencommunitycliniciansengageintrainingto

achievethefulllevelofcompetency,towhatdegreedotheirclientsimprove?Inthelargest

randomizedcontrolledtrialofanEBTforPTSDinyouths,75%ofthosediagnosedwith

PTSDpriortotreatmentwhoreceivedTF-CBTimprovedtotheextentthattheywerenot

diagnosedwithPTSDfollowingtreatmentcomparedwith49%ofthoseinthenon-EBT

controlgroup.Further,theentireEBT-treatedgroupshoweda57%reductioninPTSD


symptomseveritycomparedto39%reductioninPTSDsymptomsseverityinthenon-EBT

controlgroup(Cohen,Deblinger,Mannarino,&Steer,2004).Basedonthesepriorfindings,

anexploratoryaimofthestudywasforthemeanPTSDscoreonanobjectivemeasurefor

clientsreceivingEBTforPTSDtoreduceby50%ormorefrompre-topost-treatment.

Method

Participants

ThenationalChildren’sBureaulaunchedaninitiativetofunddemonstration

projectstodisseminateevidence-basedpracticesinchildwelfaresystemsthatfocusedon

traumaandtrauma-relatedproblems.Five-yearprojectswerefundedinchildwelfare

systemsin19differentstatesinaseriesofthreecohorts(fundedin2011,2012,and2013).

TheLouisianaChildWelfareTraumaProject(LCTP)wasoneofthefive-year

demonstrationprojectsfundedbytheChildren’sBureauwiththeirfirstyearbeginningin

2012(http://latrauma.com).TheprimarygoaloftheLCTPwastotrainLouisiana

DepartmentofChildrenandFamilyServices(DCFS)caseworkerstouseanewuniversal

screenfortraumaexposure,trauma-relatedproblems(i.e.,PTSD),andotheremotionaland

behavioralproblems.Inparallelwiththistrainingofcaseworkerstoscreenanddetect

youthsinneedofclinicalservices,anadditionalaimoftheLCTPwastoenhancetheservice

arrayinanticipationofgreaterreferrals.

ParticipantswereclinicianswhoprovidementalhealthservicestoMedicaid-eligible

childrenandadolescentsacrossthestateofLouisiana.Clinicianswhocouldpotentially

receivetrainingintheEBTforPTSDwereidentifiedusingtheexistingLouisianaMedicaid

behavioralhealthproviders’onlinedirectory.Asearchwasconductedwithinthedirectory

usingthefollowingcriteria:1)licensedclinicianswhoidentifiedthemselvesasproviding


servicestochildrenandadolescentsand2)providerslocatedwithina25-mileradiusof

DCFSofficesinthetargetregionofthestate.Providerswerealsoidentifiedbyaskinglocal

DCFSadministratorsandstaffforalistoflicensedcliniciansandagenciestowhomthey

regularlyreferchildrenforpsychotherapy.Cliniciansfrompublicallyfundedbehavioral

healthservicesclinics,(“HumanServicesDistricts”),werealsoinvitedtothetraining.Some

clinicianslearnedaboutthetrainingbyword-of-mouth.Astheprojectprogressed,the

trainingwasavailabletocliniciansfromregionswheretraininghadalreadybeenprovided

toallowclinicianswhohadmissedprevioustrainingstoattend.

YouthsseenbycliniciansreceivingtrainingthroughtheLCTPweredetermined

eligibletoreceivetheEBTtypicallyiftheydisplayedsignificantsymptomsofPTSD,usually

meetingthecutoffscoreonthemeasuredevelopedfortheLCTP.Theappropriatenessof

clientstoreceivetheEBTwasdiscussedduringconsultationcalls(describedbelow).Given

thattheinformationaboutyouthparticipantswaslimitedtowhatwasneededtoconsultto

cliniciansinscreeningforPTSD,detaileddemographicswerenotcollected.Justlessthan

halfoftheyouthswhoweretrackedbytheclinicianswereinvolvedwithDCFS.TheLCTP

didnotinterfereindecision-makingaboutwhichclientswerereferredtospecificclinicians

fortreatment.Thetrainertrackedtheprogressofclientsdiscussedduringcallsbutdidnot

trackthenumberofclientswhoweredeterminedineligiblefortreatment,thosewho

droppedoutoftreatmentpriortocompletion,orwhetherornottheycontinuedin

treatmentbeyondthecompletionoftheEBTforPTSD.Theprojectwasreviewedand

approvedbytheTulaneUniversityCommitteeontheUseofHumanSubjects.Theproject

metanexemptiondeterminationandinformedconsentswerenotrequired.

Procedures


ThechildwelfaresysteminLouisianaisastatewidesystemthatisadministeredby

DCFS.Thestateisdividedintoninegeographicregions.TheLCTProlledout

implementationofDCFScaseworkertrainingtousetheTraumaandBehavioralHealth

(TBH)screenandsimultaneouscliniciantrainingtolearntheEBTforPTSDoneregionata

time.Atrainingmodelwascreatedthatcouldreachanywillingsolopractitionerwith

minimaltravel,cost,andtimeinvolvedfortraineesandtrainer.Trainingsweredelivered

tocliniciansinonetotworegionsatagiventimeoverthecourseoffouryears.Pre-and

post-TBHsofclientsreceivingtheEBTwerecollectedbyclinicianscompletingcase

consultationwhenpossible.

YouthPTSDTreatmenttraining.YouthPTSDTreatment(YPT;Scheeringa&

Weems,2014)isanindividuallydelivered,12-sessionmanualizedcognitive-behavioral

therapy(CBT)foryouth,agessevento18years,withPTSD.YPTwaschosenbecauseofits

highlystructured,manual-basedformatthatfacilitatesdisseminationamongnoviceCBT

therapists.YPTincludestraditionalcomponentsofCBTforchildhoodtraumaincluding

psychoeducation,skillbuildinginidentificationandexpressionofemotions,relaxation

exercises,explorationofnegativethoughts,narrativeprocessingoftraumaevents,graded

exposureexercisesinandoutoftheoffice,safetyplans,andinvolvementofcaregiversin

everysession.TheYPTmanualisanolder-ageextensionofthePreschoolPTSDTreatment

(PPT)manualthathasshowngoodefficacyinaprevioustrialwithchildren,agesthreeto

sixyears(Scheeringa,Weems,Cohen,Amaya-Jackson,&Guthrie,2011).Theefficacyof

YPTforthetreatmentofPTSDsymptomsforolderchildrenhasbeendescribedpreviously

(Humphreys,Weems,&Scheeringa,2015;Scheeringa&Weems,2014).

In-persontraining.Clinicianswereinitiallyinvitedtoattendaone-day,in-person


trainingtobeheldintheirgeographicalregionbymailoremail.Atotalof10trainings

acrossthenineregionswereheld.Interestedclinicianscompletedanapplicationforthe

training,whichincludedquestionsaboutclinicians’credentialsandwhetherornotthey

wereMedicaidproviders,andthereforeeligibletoservechildreninvolvedwithDCFS.In

addition,applicantswereaskedtoagreetocompleteatleastonecaseusingtheYPTmodel

andtoattendweeklyconsultationcallsforsixtoninemonthstoreceivecaseconsultation.

Participationwasvoluntaryandwasnotmandatedbytheclinician’sagencymanagement,

DCFS,managedcareprovidersorotherentities.Alltrainingsessionswerefreeofchargeto

clinicians.

Thetrainer(andfirstauthor)wasapsychologist,licensedtopracticeintheStateof

Louisiana,withexpertiseinworkingwithtraumatizedchildreninvolvedwithchildwelfare.

Atthestartoftraining,shehadsevenyearsofexperienceconducting,supervisingand

consultingontheuseofYPTwithchildrenofallages.

Theone-day,6.5-hourtrainingcoveredassessmentanddiagnosisofPTSD,including

theuseoftheTBH,andthecontentoftheYPTmanualindetail.TheYPTmanualand

handoutswereprovidedtoeachparticipant.Videoexcerptsfromactualtreatment

sessionswereusedtoillustratetreatmentcomponents.Interactiveexercisesallowedfor

participantstopracticetreatmenttechniques.Aportionofthetrainingalsocovered

specialconsiderationsforprovidingYPTtoyouthinvolvedwiththechildwelfaresystem,

includingidentifyingwhichtraumaticeventstotargetintreatment,workingwithfoster

parents,andcommunicationwithDCFSandthecourts.Continuingeducationcreditswere

providedtoeligibleclinicians.

Teleconferenceconsultation.Approximatelyoneweekfollowingthein-person


training,thetraineremailedparticipantsinvitingthemtosignupforweeklyconsultation

calls.Generally,groupswereformedwithonetofiveclinicians.Groupswerekeptsmallin

orderforeachcliniciantohavetheopportunitytoreceiveconsultationonaweeklybasis.

Aneffortwasmadetogroupcliniciansfromthesameagencytogetherwithnooutside

cliniciansinordertobeabletodiscussagency-specificpoliciesthatmaybeimpactingthe

deliveryofYPT.

Theone-hourcallsweregenerallyheldonaweeklybasisforsixtoninemonthsfor

cliniciansinthetargetregion.Occasionally,acliniciancompletedacasewithinthree

monthsanddiscontinuedconsultationfollowingthecompletionofthecase.Onegroupof

twocliniciansfromthesameagencyattendedcallsforover12monthsduetodifficulty

withretainingclientsinservices.

Attheoutset,thetrainerexplainedthenatureofconsultationandthefactthatthe

therapistwasultimatelyresponsibleforthecareoftheclient.Thetrainerusedacognitive-

behavioralframeworkforconsultationcallsinordertomodelthisapproachfor

participantsandthiswasdiscussedduringthefirstcalltosetexpectations.Thetrainer

emphasizedthatconsultationwouldfocusonPTSD,individualYPTsessions,andissues

relatedtodeliveringYPTtochildreninvolvedwithDCFS.Althoughthecallswere

structured,therewasflexibilitytoallowforclinicianstoaskquestionsanddiscuss

facilitatorsandbarrierstodeliveringthetreatment.Anagendaforeachcallwasset

betweenthetrainerandtheparticipants,includingallocatinganequitableamountoftime

foreachcliniciantodiscusstheircase.

Contentofcalls.Identificationofclientswhowouldbeappropriatetoparticipatein

YPTcomprisedasignificantportionofthediscussionsduringinitialcalls.Cliniciansfirst


presentedbackgroundinformationonthecase(e.g.,ageofyouth,traumaexposure,child

welfarestatus,andlivingsituation)andthenprovidedtheresultsoftheTBH.Thetrainer

andcliniciantogetherdeterminedtheappropriatenessofbeginningYPTwiththeclient.

Onceanappropriateclientwasidentified,thetrainerreviewedthemanualcontentand

providedstep-by-stepinstructionsfordeliveringeachsessionofYPT.Thetrainermade

suggestionsfortailoringsessionstomeettheneedsofeachindividualclientwhile

maintainingfidelitytothemodel.Assessionsprogressed,clinicianspresentedtheevents

thatoccurredduringthepreviousweek’ssessionandreceivedfeedbackfromthetrainer.

Thetrainerthenpreviewedtheupcomingsession.

TBHadministration.Withtheexceptionofthefirstregionparticipatinginthe

training,clinicianswereaskedtoadministertheTBHtoscreenyouthsforPTSDandassist

indeterminingeligibilityfortreatment.ThecliniciansadministeredtheTBHtochildren

agessevenyearsandup.TheyalsoadministeredtheTBHtocaregiversoftheseyouths,as

wellastocaregiversofyouthsbetweentheagesofthreeandsixyears.Cliniciansconsulted

withthetrainerasneededtoreviewadministration,scoring,andinterpretationoftheTBH.

ClinicianswerealsoaskedtoadministertheTBHfollowingthecompletionoftreatment

whenpossibletodetermineclinicalprogress.CliniciansreportedTBHscorestothe

trainer,pre-andpost-treatmentwhenavailable,whorecordedtheminanExcel

spreadsheet.

Measure

TheTBHwascreatedforthisprojectandconsistsofcomponentstakenfromfour

existinginstrumentsinthepublicdomain(availableathttp://latrauma.com).Themeasure

includesitemsformingfoursubscalesassessingPTSD,internalizingsymptoms,ADHD,and


externalizingsymptoms.TheTBHalsocontains11questionstocoversubstanceabuse,

psychosis,autism,andpreschoolissues,buttheseitemsdonotfigureintothescoringof

subscales.Acaregiver-reportversionoftheTBHwasdevelopedforcaregiversofchildren,

ages0to18years.Ayouth-reportversionwasdevelopedforchildren,agessevento18

years,withthesameitemsasthecaregiverversionbutpronounsmodifiedappropriately

forself-administration.

OnlythePTSDsubscalewasusedinthecurrentstudy.Thissubscaleconsistsof15

itemsfromthe17-itemChildPTSDSymptomScale(CPSS;Foa,Johnson,Feeny,&

Treadwell,2001).TwoitemswerenotretainedfromtheCPSS,includingtheitemfornot

beingabletorememberanimportantpartofthetrauma.Thisitemhasbeenshown

consistentlytobeoneoftheleastfrequentlyendorseditems(Saul,Grant&Carter,2008;

Scheeringaetal.,2003)andposesdevelopmentalchallengesforaccurateendorsementin

youngerchildren(Scheeringa,2009).Theotheritemthatwasnotretainedwasdifficulty

concentratingbecausethiswasaskedaboutinadifferentsectionoftheTBHandwas

thoughttobeconfusingifaskedabouttwice.TheitemsmapdirectlyontotheDiagnostic

andStatisticalManualofMentalDisorders,FourthEdition(APA,1994)PTSDsymptoms,

andwereeachratedonafour-point(0-3)Likertscale.ThereliabilityforthePTSDsubscale

oftheTBHisverygood(α=.91forcaregiver-reportandα=.93foryouth-report).Ascoreof

11isrecommendedastheclinicalcutoffwhenusingthefullCPSS(Foaetal.,2001).Ascore

of10onthePTSDsubscalewasusedasthecutoffintheLCTPbecausewedidnotusetwo

oftheCPSSitems.

DataAnalysis

Theaimofourfirstresearchquestionwasthat80%ofclinicianswhoattendedthe


trainingwouldachievetheAdvancedleveloftraining.Because80%wasonlyabenchmark

suggestedbyotherexpertsinthefield(Dorseyetal.,2016)andwasnotderived

empiricallyfromapriorstudy,wedidnotfeelthatsignificancetestsofstatisticalinference

wereappropriate,andtheresultsarereporteddescriptively.

TherewerethreelevelsoftrainingatwhichclinicianswererosteredontheLCTP

website:“One-daytrained,”wasthedesignationgiventoclinicianswhoattendedonlythe

one-dayin-persontraining,includingthosewhosignedupforconsultationcallsbut

droppedoutafteroneortwocalls;“Basictraining,”indicatedthatclinicianshadattended

atleastfivegroupconsultationcallsoverapproximatelyasix-monthperiodasthey

attemptedtoidentifyclientsappropriateforthemodel.Thesecliniciansparticipatedin

otherYPTcasediscussionsbutdidnotcompletetheirowncasesusingthemodel.Oncea

clinicianhadimplementedtheYPTprotocol(completingsevento12sessions)withatleast

oneyouthandhadattendedweeklycallstoreceiveconsultationonhis/hercase,the

clinicianwasdesignatedashavingreceived“Advancedtraining”inYPT.The“Advanced”

cliniciansreceivedcertificatesofcompletionfromtheLCTP.

Todetermineclientprogress,pre-treatmentandpost-treatmentPTSDsubscale

scoresfor17youthswhocompletedYPTwerecompared,andthepercentreductionin

theirscoreswascalculated.Thispercentreductionwascompareddescriptivelytopercent

reductionsthatwereachievedwithTF-CBTinthelargestpriorstudytotreatyouthswith

posttraumaticstress(Cohenetal.,2004).

Results

ClinicianRetention

Table1andFigure1displaythenumberofcliniciansinvitedtoandthe


number/percentagethatattendedtheone-daytrainingsineachregion.Ofthe2,036

cliniciansstatewidewhowereinvitedtoatrainingsessionheldintheirgeographical

region,335(16%)attended.

Table1alsodisplaysthenumberofclinicianswhoparticipatedintheconsultation

callsandthenumberofclinicianswhocompletedtherequirementsforthedifferentlevels

oftraining.Ofthe117participantswhobeganconsultationcalls,themajority(71%)

completedatleastfivecalls.Although45(38%)ofclinicianscompletedtheAdvanced

trainingexpectations,thiswasfarlowerthanouraimof80%.Thirty-eightclinicians

(32%)completedtrainingexpectationsattheBasicleveland34clinicians(29%)signedup

forconsultationcallsbutdiscontinuedafterzerototwocalls.Finally,218clinicians

attendedthein-persontrainingbutneversigneduptoattendconsultationcalls.No

informationiscurrentlyavailableastothereasonsomanycliniciansneverattended

consultationcalls.

ClientProgress

TheaimsoftheLCTPwerenotfocusedonindividualchildPTSDtreatmentprogress

becauseofconcernsaboutcreatingresistanceamongcliniciansiftheyknewtheywouldbe

requiredtocompleteextrapaperwork.DataontheefficacyoftheYPTdeliveredare

thereforelimited.Althoughpre-treatmentTBHmeasureswereadministeredforeach

client,cliniciansreporteddifficultyincompletingpost-treatmentmeasureswithclientsand

thetrainernoteddifficultycontactingcliniciansoncetheconsultationhadfinished.

Nevertheless,thetrainertracked102clientsdiscussedduringconsultationcalls.Ofthese,

64(63%)successfullycompletedtreatmentandclinicianscompletedpre-andpost-

measureswith17.Ofthoseforwhompre-andpost-treatmentdatawereavailable,the


meanagewas8years(range=4to17).Fifteenidentifiedasfemalesandtwoidentifiedas

males.All17oftheclientsshowedareductioninPTSDscoresbyeithercaregiveroryouth

report.Accordingtotheyouths’reports,themeanPTSDscoredecreasedfrom26to11.1

(57%reduction).Themeancaregiverratingofyouthsdecreasedfrom26.5to11.5(57%

reduction).Bothoftheseresultsexceededouraimofa50%reductioninPTSDseverity.

Further,12(71%)hadareductioninpost-treatmentPTSDscorebyatleast50%ofthepre-

treatmentscore,withnine(53%)nolongermeetingthecutoffforPTSD.

Discussion

Tobegintoaddressthesignificantimpactoftraumaexposureinthechildwelfare

populationinLouisiana,theLCTPsetouttodisseminateanEBTforPTSDforclinicians

usingareplicabletrainingmodelwithanintentionallylowburden.Thisisthefirstknown

reportoftheproportionofcommunityclinicianswhocompletedconsultationcallsto

achievecompetencyfollowingtheinitialtraining.Ofthe335clinicianswhoattendedthe

initialtraining,only45(13%)completedtherequirementsforAdvancedtrainingstatus.

TheproportionofclinicianswhoachievedAdvancedtrainingstatusappearsdisappointing,

butisconsistentwithotherpreviousanecdotalreportsofpooruptakeofEBTs(McLean&

Foa,2013;Shafranetal.,2009;Zayfertetal.,2005).Ofthosewhomadethecommitment

beyondtheone-daytrainingtoattendconsultationcalls,theproportionofclinicianswho

achievedAdvancedtrainingstatuswasbetter,38%,butstillfarbelowourinitialgoalof

80%.ItisdifficulttointerpretthisresultgiventhatnopreviousstudieshavereportedEBT

trainingcompletionrates.WhileDorseyetal.(2016)providedabenchmarkof80%

cliniciancompletion,theirreportdidnotincludethenumberofcliniciansoriginallyinvited

toparticipateintrainingandcompletiondataweremissingforanumberofparticipants.


Preliminaryoutcomedatathatwerecollectedbyclinicianswhoremainedactivein

consultationcallsindicatedpositiveoutcomesfortheclients,withclients’PTSDsymptoms

beingreducedby57%,greaterthanouraimof50%,percaregiverandyouthreport.This

reductioninsymptomseverityissimilartotheresultsreportedbyCohenetal.(2004).

Theseresultsprovideuniqueevidencethatdisseminationtocommunityclinicianswhoare

willingandabletoimplementtheEBToutsideofahighlycontrolledrandomizedtrialis

possibleandeffective.

Weelectedtorecruitcliniciansdirectlyforthetrainingasopposedtotargeting

agencies.Thisapproachmayhaveappealedtocliniciansinprivatepracticeandtothose

workinginclinicsalike.ApopularmodelfortrainingcliniciansinEBTsforyouthwhohave

beenexposedtotraumahasbeenthelearningcollaborative,anintensive,multi-layered

methoddevelopedbytheInstituteforHealthCareImprovement,andheavilypromotedby

theNCTSN(e.g.,Ebert,Amaya-Jackson,Markiewicz,Kisiel,&Fairbank,2012).Learning

collaborativesoftentargetagenciesandareincreasinglyassessingandaddressingagency

readinesstoimplementaparticulartreatmentmodel.Thelearningcollaborativemodel

wasacommonchoiceamongotherChildren’sBureaucohortgrantees,butithasseveral

weaknessesthatmakeitillsuitedforastatewidedisseminationduetoseveralissuesin

Louisiana.Learningcollaborativesarelongindurationandrelativelyslowtotraina

workforcetocompetency.Theyaretimeintensiveandrequireasubstantialamountof

missedworktoattendworkshoptrainings.Barrierstoimplementingtheuseofthe

treatmentcanbetimelimitationsduetoagencyproductivityrequirements,organizational

restructuring,andstaffturnover.Learningcollaborativesaredesignedtochangeagency

culturesinrespecttotraumaawareness,andthereforeincludeadministratorsand


supervisorswhoareexpectedtoreturntotheiragenciesastraumachampions.Thisgoal

ofagencycultureshiftislessrelevantwhenconsideringthat80%ofpsychotherapy

businessesaresolopractices(Curan,2016).

AswithothereffortstodisseminateEBTs,challengeswereidentifiedduringthe

consultation.First,retentionofcliniciansintheconsultationwasnotoptimalandwas

limitedbyseveralfactors.Itispossiblethatthereasonforlackofclinicianparticipationin

theconsultationswasthattheycouldnotidentifyclientsforwhomYPTwouldbe

appropriate.ThiswasamysterytoLCTPstaffasDCFSsimultaneouslycomplainedabouta

lackofprovidersavailabletoreferto.LCTPstaffattemptedtoaddressthisproblemby

providinglistsofcliniciansacceptingreferralstoDCFSstaffduringfollow-upproject

meetings.Inaddition,theYPTtrainerencouragedclinicianstoreachouttoDCFSoffices

personallytorequestreferrals.Theseeffortsweresuccessfulinasmallnumberofcases

butstill,themajorityofclientswhoreceivedYPTwerenotinvolvedwithDCFS.Insome

cases,clientswhobeganYPTsometimesdiscontinuedduetobeingmovedtoafosterhome

inanotherregionorduetocaregiversreportingtoomanystressorstoattendweekly

sessions.Theseissueswereaddressedrepeatedlyinconsultationcallsandclinicians

sometimeswereabletoproblem-solveinordertoretainclients.Forexample,clinicians

wereencouragedtoreachouttoDCFSworkersinordertoengagefamilies.Also,sessions

wereofferedeveryotherweekormultipletimesperweekinordertoaccommodatethe

family’sschedule.InordertoexpandthepoolofEBT-trainedproviders,wedidnotrequire

clinicianstoseeyouthsinvolvedwithDCFSatthetimeofthetraining,onlythatthey

acceptedMedicaidandcouldpotentiallybeprovidersforDCFS-referredyouthsinthe

future.Thus,theLCTPincreasedthenumberofclinicianswithAdvancedtrainingto


effectivelytreatchildrenwithPTSDinvolvedinchildwelfareacrossLouisianaby45

individuals.Despitetheeffortsinthisproject,furtherintensiveworkneedstobedoneto

makethechildwelfaresystemmoretrauma-informedandtoprioritizestabilityfor

childrensothattheymayreceivethecaretheyneed.Thisimportantsystems-levelwork

wasbeyondthescopeofourstudy.

Anotherissuepossiblyimpactingtheretentionofcliniciansinthetrainingwasthe

timerequiredtocompletetheconsultationcalls,especiallyforthosewithprivatepractices.

Althoughmanyagencymanagersallowedforprotectedtimeforclinicianstoreceivethe

training,somecliniciansinprivatepracticewereunabletocarveouttimetoparticipatein

weeklycalls.Thisbarrierremaineddespiteeffortstoaddressit,includingthetrainerbeing

availableoutsideoftraditionalbusinesshours.

RegardingtheimplementationofYPT,onelimitationoftheprojectwasthatdelivery

ofYPTwastrackedusingself-reportduringconsultationcallsonly.Whilethetrainer

carefullyinquiredaboutandmonitoredfidelitytothemodelwitheachclinician,therewas

nodirectobservationoftheclinician’sservicedelivery,norcollectionofreportsfrom

supervisorsorclientsinmostcases.Further,cliniciansreportedafairamountof

avoidanceonthepartoftheclientandcaregiver.Insomeinstances,cliniciansalso

disclosedtheirownavoidanceduetotheemotionallyintensenatureofthetraumaticevent

beingaddressed.Thetrainerwelcomedthesediscussionsaboutavoidanceandclient,

caregiver,andtherapistreluctancetocompletethetreatmentwasaddressedfromthe

outsetofconsultationandthroughoutthecourseofthecalls.Troublewithshiftingfroma

nondirectivetoadirectiveapproachwasalsoreportedbysomecliniciansduringcalls.In

thesecases,thetrainernormalizedthischallengeandenlistedtheassistanceofother


membersofthecalltovalidateandsharestrategies.

OurobservationsaresimilartothosedescribedbyHansonetal.(2014),who

interviewed19approvednationalTF-CBTtrainersabouttheirperceptionsofchallengesto

theimplementationofTF-CBT.Trainersbelievedsomeproviderslackedbasictrainingin

CBTandhadtroubleshiftingfromanondirectivetoamoredirectiveapproach.

Intervieweesalsoreportedthatavoidanceofdirectlytalkingaboutthetraumawas

experiencedbothbyclients,caregivers,andattimes,clinicians,andthatthiswasa

significantbarriertothedeliveryofTF-CBTwithfidelity.

Onewaytoimprovefidelitytrackinginthefutureistoincludevideoreviewof

treatmentsessionsaspartofthetraining.Althoughthismayposeabarriertoclinicians

signingupforsuchtraining,improvedandlessexpensivetechnologyismakingtheuseof

thesetrainingmethodsincreasinglypossible.

Anotherlimitationistheverylowrateofpost-treatmentTBHcollection.Although

thetrainertrackedclientprogressthroughclinicianreportqualitativelyduringcalls,itis

possiblethatcliniciansinadvertentlyavoidedpost-treatmentdatacollectionwiththose

clientswhoappearedasiftheywerenotimproving.Further,asthisprojectwasnot

designedasarandomizedcontrolledtrial,thelackofacontrolgroupandthelackof

randomizationofyouthstotreatmentconditionalsolimitthegeneralizabilityofthe

conclusionsthatcanbedrawnfromtheavailableclientdata.Forexample,forasubsetof

individuals,PTSDsymptomscanimprovesimplywiththepassageoftimeandthelackofa

controlgroupmadethisimpossibletoassessinourstudy.

ConclusionsandFutureProspects


Ourexperiencehighlightsthemajorlimitationsofcommunity-baseddissemination

effortsandprovidessomeinsightsforfuturedirections.Financialincentivesmaybeone

waytoincreasethenumberofclinicianswhoreceivetrainingsinandimplementEBTs.

Somestates,e.g.,CaliforniaandNorthCarolina,withintheirMedicaidprogramsoffersome

programsforhigherreimbursementratesfortheprovisionofEBTsbutthemajorityof

statesand/orprivateinsuranceagencieshavebeenslowtoadoptthispractice.Auditsand

performancefeedbackmaybeothermethodstoenhanceadoptionofEBTsastheyhave

showneffectivenesstoimprovequalityofcareacrossotherhealthcaresectors(Flottorp,

Jamtvedt,Gibis,&McKee,2010).Inthepracticeofpsychotherapy,wheremany,ifnot

most,cliniciansworkoutsideofagencies,andthepsychologicalproblemsarecomplex,

innovativeandnewmethodswillberequiredtomakesubstantialprogressinthisarea.

Inconclusion,findingsfromthepresentprojectindicatethateffectivetraininginan

EBTforPTSDforchildreninvolvedinthechildwelfaresystemispossiblewithminimal

burdenonthetrainer,clinicianand/oragency.However,thisoptimismoughttobe

temperedbythedisappointinglylowproportionsofclinicianswhoelectedtoengagein

suchtraining.Thesefindingsareimportantinlightofthenumerouspreceding

disseminationprojectssupportedwithpublicfundsthatneglectedtogathersuchbasic

metricsasproportionsofclinicianswhoachievedcompetencyandwhetherpatients

improvedornot.Muchworkisneededtomovethefieldforwardandachievethepromise

ofdisseminationofbestpracticesforchildrenandadolescents.


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Table1

NumberofCliniciansWhoCompletedDifferentLevelsofTrainingineachofNineRegionsandStatewide(PercentageinParentheses)LevelofTraining

1 2 3 4 5 6 7 8 9 Statewide

Invitedtotraining

70

157

106

86

152

577

500

156

232

2036

Attendedone-daytraining

26

26

28

16

14

51

91

41

42

335/2036(16)

Began

consultationcalls

24

19

13

0

5

8

28

13

7

117/335(35)

CompletedAdvancedtraining

10

6

6

0

2

2

11

5

3

45/117(38)

CompletedBasictraining

4

7

5

0

3

3

8

4

4

38/117(32)

Droppedoutafterlessthantwocalls

--

--

--

--

--

--

--

--

--

34/117(29)

One-daytrainedonly(neverbegancalls)

--

--

--

--

--

--

--

--

--

218/335(65)

Note.--Datamissing


Figure1.Clinicianretentionintraining.“AdvancedTraining”=completedoneYPTcaseandattendedweeklyconsultationcallsoverthreetosixmonths;“BasicTraining”=attendedatleast5consultationcallsoversixmonths.

2,036invitedtotraining

335attended1-daytraining

117beganconsultation

calls

45completedAdvancedTraining

38completedBasic

Training

34didnotcomplete

consultationcalls

a statewide training of community clinicians to treat ... · youths who have been traumatized,...

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