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Dialectical behavioral therapy for complex posttraumatic stress disorders (DBT-PTSD) is a modular treatment program that was developed at the Central Institute for Mental Health at the University of Heidelberg, Germany in 2005-2021. DBT-PTSD is designed to meet the needs of patients with complex PTSD related to sexual or physical trauma in childhood and adolescence. It is specifically designed for patients suffering from severe emotional dysregulation, persistent self-injury, chronic suicidal ideation, severe dissociative symptoms and a markedly negative self-concept with a high level of guilt, shame, self-loathing and interpersonal problems. To address these different core symptoms, DBT-PTSD combines evidence-based therapeutic strategies: principles, rules, and skills of DBT, trauma-specific cognitive and exposure-based techniques, imaginative interventions and procedures for behavioral change. The treatment program is designed to be carried out in an outpatient (45 weeks) or residential (12 weeks) setting. The results from two randomized controlled trials showed large effect sizes across very different symptom domains and a significant superiority of DBT-PTSD over Cognitive Processing Therapy (CPT). Based on these results, DBT-PTSD is currently a promising evidence-based treatment program for all features of a complex PTSD after sexual abuse in childhood and adolescence.

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This study explored predictors of community-based providers' adherence to MATCH, a modular cognitive behavioral therapy for children and adolescents. Provider-reported adherence to MATCH was measured using three increasingly strict criteria: (1) session content (whether the session covered MATCH content consistent with the client's target problem), (2) session content and sequencing (whether the session covered MATCH content in the expected sequence for the client's target problem), and (3) session content, sequencing, and participant (whether the session covered MATCH content in the expected sequence and with the expected participant(s) for the client's target problem). Session, client, provider, and organizational predictors of adherence to MATCH were assessed using multilevel modeling. Results revealed that nearly all providers delivered MATCH content that corresponded to the target problem, but only one-third of providers delivered MATCH content in the expected sequence and with the expected participant for the client's target problem. This difference underscores the need for nuanced adherence measurement to capture important implementation information that broad operationalizations of adherence miss. Regardless of the criteria used providers were most adherent to MATCH during sessions when clients presented with interfering comorbid mental health symptoms. This suggests that the design of MATCH, which offers flexibility and structured guidance to address comorbid mental health problems, may allow providers to personalize treatment to address interfering comorbidity symptoms while remaining adherent to evidence-based practices. Additional guidance for providers on managing other types of session interference (e.g., unexpected events) may improve treatment integrity in community settings.

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ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition; therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence of a coherent evidence base, treatment tended to involve multiple treatments for these multiple conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care, which highlights the importance of patient choice in identification and sequencing in targeting CPTSD symptoms. Directions for future research are discussed.

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The efficacy of modular evidence-based psychological treatments is promising, yet variation in module delivery is understudied. This study evaluated module delivery of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) and its impact on patient outcomes. Adults (N = 108) with serious mental illness and sleep and circadian dysfunction treated in a community setting were randomized to receive TranS-C plus usual care, or 6 months of usual care followed by delayed treatment with TranS-C. Data from both conditions were combined to maximize power. These secondary analyses tested whether the "dosage" of module delivery (defined as the proportion of total sessions in which a module was delivered) predicted treatment response, measured as functional impairment, psychiatric symptoms, sleep and circadian dysfunction, and sleep health, at post-treatment and 6-month follow-up. Higher dosages of seven modules were associated with improvement in the outcome variables (ßs = -0.11-0.44; ps = 0.000-0.030). Higher dosages of three modules were associated with a worsening of one or two outcome variables (ßs = 0.22-0.29; ps = 0.001-0.043). Higher dosages of the remaining modules were not associated with outcomes. Although more evidence is needed, it may be wise to consider focusing provider trainings on ensuring fidelity to certain modules, given limited training time in community settings. ClinicalTrials.gov Identifier: NCT02469233, registered June 9, 2015.

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BACKGROUND: Depression is a serious disorder in childhood and adolescence. Affected children and adolescents show significant impairments in various aspects of life. Studies on the effectiveness or efficacy of psychotherapy in depressed children and adolescents are qualitatively very heterogeneous and reveal small effect sizes. There is thus a need to better tailor psychotherapy approaches to these age groups to improve outcomes like parent-child relationship, symptomatology, or quality of life. To address this gap, we designed a modular, individualized treatment program for children and adolescents based on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) including caregiver involvement. METHOD: This quasi-experimental pilot feasibility trial is a phase 1 to phase 2 study investigating the feasibility and effectiveness of CBASP@YoungAge by including an intervention group (CBASP@YoungAge) and a treatment-as-usual control group. The treatment of depressive symptoms as well as interpersonal problems with primary caregivers are the main targets of CBASP@YoungAge. Personalization is ensured concerning the treatment course, caregivers' involvement, and the patient's age. The primary outcome relates to two areas: the feasibility of the CBASP@YoungAge treatment program in an outpatient context and a change in patients' depressive symptomatology from before to after treatment. We conduct a brief process evaluation after each session in the intervention group to closely monitor the treatment process and examine feasibility from the therapists' and patients' perspectives and mechanisms of symptom change. In addition, we consider interpersonal behavior between children and caregivers, parenting behavior, and monitor the global-health-index in children and parents as secondary outcomes. Pre-, post-, and follow-up data are evaluated. DISCUSSION: This is the first study of a modular-based intervention program for children and adolescents with depression and a clear focus on the interpersonal problems between the depressed young patient and her/his caregiver. It will provide important knowledge on the feasibility and effectiveness of the program and potential benefits of including caregivers in psychotherapy. Based on this study's results, we plan a multicenter, randomized, controlled trial whose long-term aim is to improve the psychotherapeutic care of young patients with depression while preventing persistent courses of depressive disorders. TRIAL REGISTRATION: German Clinical Trials Register, DRKS (identifier DRKS00023281 ). Registered 17 November 2020-Retrospectively registered.

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Given that over 20 million adults each year do not receive care for their mental health difficulties, it is imperative to improve system-level capacity issues by increasing treatment efficiency. The present study aimed to collect feasibility/acceptability data on two strategies for increasing the efficiency of cognitive behavioral therapy: (1) personalized skill sequences and (2) personalized skill selections. Participants (N = 70) with anxiety and depressive disorders were enrolled in a pilot sequential multiple assignment randomized trial (SMART). Patients were randomly assigned to receive skill modules from the Unified Protocol in one of three sequencing conditions: standard, sequences that prioritized patients' relative strengths, and sequences that prioritized relative deficits. Participants also underwent a second-stage randomization to either receive 6 sessions or 12 sessions of treatment. Participants were generally satisfied with the treatment they received, though significant differences favored the Capitalization and Full duration conditions. There were no differences in trajectories of improvement as a function of sequencing condition. There were also no differences in end-of-study outcomes between brief personalized treatment and full standard treatment. Thus, it may be feasible to deliver CBT for personalized durations, though this may not substantially impact trajectories of change in anxiety or depressive symptoms.

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Background: Achieving high quality outcomes in a community context requires the strategic coordination of many activities in a service system, involving families, clinicians, supervisors, and administrators. In modern implementation trials, the therapy itself is guided by a treatment manual; however, structured supports for other parts of the service system may remain less well-articulated (e.g., supervision, administrative policies for planning and review, information/feedback flow, resource availability). This implementation trial investigated how a psychosocial intervention performed when those non-therapy supports were not structured by a research team, but were instead provided as part of a scalable industrial implementation, testing whether outcomes achieved would meet benchmarks from published research trials. Method: In this single-arm observational benchmarking study, a total of 59 community clinicians were trained in the Modular Approach to Therapy for Children (MATCH) treatment program. These clinicians delivered MATCH treatment to 166 youth ages 6 to 17 naturally presenting for psychotherapy services. Clinicians received substantially fewer supports from the treatment developers or research team than in the original MATCH trials and instead relied on explicit process management tools to facilitate implementation. Prior RCTs of MATCH were used to benchmark the results of the current initiative. Client improvement was assessed using the Top Problems Assessment and Brief Problem Monitor. Results: Analysis of client symptom change indicated that youth experienced improvement equal to or better than the experimental condition in published research trials. Similarly, caregiver-reported outcomes were generally comparable to those in published trials. Conclusions: Although results must be interpreted cautiously, they support the feasibility of using process management tools to facilitate the successful implementation of MATCH outside the context of a formal research or funded implementation trial. Further, these results illustrate the value of benchmarking as a method to evaluation industrial implementation efforts.Plain Language Summary: Randomized effectiveness trials are inclusive of clinicians and cases that are routinely encountered in community-based settings, while continuing to rely on the research team for both clinical and administrative guidance. As a result, the field still struggles to understand what might be needed to support sustainable implementation and how interventions will perform when brought to scale in community settings without those clinical trial supports. Alternative approaches are needed to delineate and provide the clinical and operational support needed for implementation and to efficiently evaluate how evidence-based treatments perform. Benchmarking findings in the community against findings of more rigorous clinical trials is one such approach. This paper offers two main contributions to the literature. First, it provides an example of how benchmarking is used to evaluate how the Modular Approach to Therapy for Children (MATCH) treatment program performed outside the context of a research trial. Second, this study demonstrates that MATCH produced comparable symptom improvements to those seen in the original research trials and describes the implementation strategies associated with this success. In particular, although clinicians in this study had less rigorous expert clinical supervision as compared with the original trials, clinicians were provided with process management tools to support implementation. This study highlights the importance of evaluating the performance of intervention programs when brought to scale in community-based settings. This study also provides support for the use of process management tools to assist providers in effective implementation.

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Decentralized water recycling systems (DWRS) have emerged as a viable option for incrementally augmenting water supply in water-stressed regions, but DWRS are generally more energy-intensive than traditional centralized water treatment systems. When DWRS are deployed incrementally in small batches, the marginal energy intensity (MEI) of water supply quantifies the location-specific energy footprint of centralized water supply and serves as a robust metric measuring the energy implications of replacing centralized supply with DWRS supply. This research develops and applies a MEI-based decision framework that identifies the energy-optimal siting of DWRS to minimize the overall system operational energy consumption given a target fraction of water demand to be met by newly deployed DWRS. In a small benchmark water supply system where the energy intensity of the intended DWRS is 5.3% higher than the current system average energy intensity of centralized supply, we demonstrate that the optimal siting of DWRS to offset 10% of the system-wide water demand reduces the overall system energy consumption by 0.77%. In contrast, the naive and worst-case siting of the same DWRS increases the energy consumption of the overall system by 0.65 and 2.0%, respectively. The proposed MEI-based decision framework is particularly valuable for application in large multi-source systems, where an optimization-based approach is computationally intractable. This study highlights the importance of accounting for both distribution and treatment energy intensity when evaluating new water sources and demonstrates the viability of DWRS as an energy-efficient tool for augmenting water supply.

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Introduction: Schools have become a primary setting for providing mental health care to youths in the U.S. School-based interventions have proliferated, but their effects on mental health and academic outcomes remain understudied. In this study we will implement and evaluate the effects of a flexible multidiagnostic treatment called Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) on students' mental health and academic outcomes. Methods and Analysis: This is an assessor-blind randomized controlled effectiveness trial conducted across five school districts. School clinicians are randomized to either MATCH or usual care (UC) treatment conditions. The target sample includes 168 youths (ages 7-14) referred for mental health services and presenting with elevated symptoms of anxiety, depression, trauma, and/or conduct problems. Clinicians randomly assigned to MATCH or UC treat the youths who are assigned to them through normal school referral procedures. The project will evaluate the effectiveness of MATCH compared to UC on youths' mental health and school related outcomes and assess whether changes in school outcomes are mediated by changes in youth mental health. Ethics and Dissemination: This study was approved by the Harvard University Institutional Review Board (IRB14-3365). We plan to publish the findings in peer-reviewed journals and present them at academic conferences. Clinical Trial Registration: ClinicalTrials.gov ID: NCT02877875. Registered on August 24, 2016.

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This discussion article begins by highlighting two trends apparent in the field of child maltreatment. The first, an awareness that multiple forms of maltreatment - polyvictimization - is the rule in populations of abused and neglected children rather than the exception. The second is that current types of child maltreatment are being extended to include Adverse Childhood Experiences (ACEs). These include intra-familial violence, mental health, substance misuse, and inter-generational abuse. The paper introduces an innovative strategy to help the field better organise and prevent the extensive sequelae of polyvictimization and ACEs. This strategy involves the development of a modular approach, which identifies common treatment elements and common factors across the field of effective interventions and organizes them, providing a co-ordinated framework for practitioners to use to address the diverse needs of children and families when vulnerability or maltreatment are identified. The development of this approach, the Hope for Children and Families (HfCF) Intervention Resources, is described using a case example to illustrate its logic and structure. Findings from the HFCF pilot and subsequent training programs suggest that this new approach could be an important milestone in the protection of children from violence, abuse and neglect on the 30th Anniversary of the United Nation's Convention on the Rights of the Child (1989).

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OBJECTIVE: Little is known about the optimal treatment of avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate feasibility, acceptability, and proof-of-concept for cognitive-behavioral therapy for ARFID (CBT-AR) in children and adolescents. METHOD: Males and females (ages 10-17 years) were offered 20-30 sessions of CBT-AR delivered in a family-based or individual format. RESULTS: Of 25 eligible individuals, 20 initiated treatment, including 17 completers and 3 dropouts. Using intent-to-treat analyses, clinicians rated 17 patients (85%) as "much improved" or "very much improved." ARFID severity scores (on the Pica, ARFID, and Rumination Disorder Interview) significantly decreased per both patient and parent report. Patients incorporated a mean of 16.7 (SD = 12.1) new foods from pre- to post-treatment. The underweight subgroup showed a significant weight gain of 11.5 (SD = 6.0) pounds, moving from the 10th to the 20th percentile for body mass index. At post-treatment, 70% of patients no longer met criteria for ARFID. DISCUSSION: This is the first study of an outpatient manualized psychosocial treatment for ARFID in older adolescents. Findings provide evidence of feasibility, acceptability, and proof-of-concept for CBT-AR. Randomized controlled trials are needed.

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This study explored whether post-treatment symptom severity moderated the association between session attendance during an initial treatment episode and subsequent mental health service use. Data on attendance, symptom severity, and service use were gathered from an effectiveness trial testing a modular treatment for youth anxiety, depression, disruptive behavior, and traumatic stress. Multilevel logistic regression analyses showed a significant interaction between attendance and post-treatment symptom severity on subsequent service use, such that attendance significantly predicted subsequent service use when post-treatment symptom severity was in the normal range. Implications regarding the influence of treatment engagement on future help-seeking are discussed.

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There is strong enthusiasm for utilizing implementation science in the implementation of evidence-based programs in children's community mental health, but there remains work to be done to improve the process. Despite the proliferation of implementation frameworks, there is limited literature providing case examples of overcoming implementation barriers. This article examines whether the use of three implementations strategies, a structured training and coaching program, the use of professional development portfolios for coaching, and a progress monitoring data system, help to overcome barriers to implementation by facilitating four implementation drivers at a community mental health agency. Results suggest that implementation is a process of recognizing and adapting to both predictable and unpredictable barriers. Furthermore, the use of these implementation strategies is important in improving implementation outcomes.

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Most patients in community practice attend significantly fewer sessions than are recommended by treatment protocols that have demonstrated efficacy in addressing emotional disorders. Personalized interventions that target the core processes thought to maintain a wide range of disorders may serve to increase treatment efficiency, addressing this gap. This study sought to evaluate the feasibility and acceptability of the personalized delivery of a mechanistically transdiagnostic intervention, the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders. Using an AB phase change design in accordance with the single-case reporting guideline for behavioral interventions (SCRIBE), 18 individuals with heterogeneous emotional disorders were randomly assigned to receive UP treatment modules ordered according to either their pretreatment strengths or weaknesses. Results support the feasibility of reordering the treatment modules as the majority of patients presented with marked differences in skill levels, as well as the acceptability of this approach as patients in both conditions reported satisfaction with their assigned treatment order. Furthermore, the majority of patients demonstrated symptom improvement consistent with previously reported effects of the standard-order UP. Finally, there is preliminary evidence to suggest that those in the strengths condition displayed improvements in outcomes earlier in treatment than those in the weaknesses condition. Taken together, these findings offer preliminary support for improving treatment efficiency through the utilization of a personalized, strengths-based, transdiagnostic approach.

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BACKGROUND: Despite the high persistence rate of attention-deficit/hyperactivity disorder (ADHD) throughout the lifespan, there is a considerable gap in knowledge regarding effective treatment strategies for adolescents with ADHD. This group in particular often shows substantial psychosocial impairment, low compliance and insufficient response to psychopharmacological interventions. Effective and feasible treatments should further consider the developmental shift in ADHD symptoms, comorbidity and psychosocial adversity as well as family dysfunction. Thus, individualised interventions for adolescent ADHD should comprise a multimodal treatment strategy. The randomised controlled ESCAadol study addresses the needs of this patient group and compares the outcome of short-term cognitive behavioural therapy with parent-based telephone-assisted self-help. METHODS/DESIGN: In step 1, 160 adolescents aged 12 to 17 years with a diagnosis of ADHD will undergo a treatment as usual (TAU) observation phase of 1 month. In step 2, those still severely affected are randomised to the intervention group with an Individualised Modular Treatment Programme (IMTP) or a telephone-assisted self-help programme for parents (TASH) as an active control condition. The IMTP was specifically designed for the needs of adolescent ADHD. It comprises 10 sessions of individual cognitive behavioural therapy with the adolescents and/or the parents, for which participants choose three out of 10 available focus modules (e.g. organisational skills and planning, emotion regulation, problem solving and stress management, dysfunctional family communication). TASH combines a bibliotherapeutic component with 10 counselling sessions for the parents via telephone. Primary outcome is the change in ADHD symptoms in a clinician-rated diagnostic interview. Outcomes are assessed at inclusion into the study, after the TAU phase, after the intervention phase and after a further 12-week follow-up period. The primary statistical analysis will be by intention-to-treat, using linear regression models. Additionally, we will analyse psychometric and biological predictors and moderators of treatment response. DISCUSSION: ESCAadol compares two short-term non-pharmacological interventions as cost-efficient and feasible treatment options for adolescent ADHD, addressing the specific needs and obstacles to treatment success in this group. We aim to contribute to personalised medicine for adolescent ADHD intended to be implemented in routine clinical care. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), Current Controlled Trial DRKS00008974, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00008974 ; http://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008974 ; Registered on 28 December 2015.

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Back pain and diseases of the spine are today a health disorder of outstanding epidemiological, medical, and health economic importance. The cost of care for patients with lumbosciatic complaints are steadily increasing. Accordingly, the guidelines and treatments are constantly renewed. One concept is the orthotic care. In the following we want to give an overview of the literature and the effectiveness of lumbar orthoses in low back pain supplemented by our own data. A prospective randomized study with 230 patients, divided into three groups, each with two subgroups. Three Orthoses by the TIGGES-Zours GmbH were prescribed; a demountable two-step lumbar orthosis, three-step bridging orthosis and a four-step flexion orthosis modular system. Each were compared to the nonmodular equivalent. All six groups showed improvement in pain intensity and functional capacity at 6 and 12 weeks. The modular groups were found to have improvement in the frequency of use. The subjective effectiveness and sensitivity for the modular and non-modular groups was assessed as being good. In the literature, there are no clear guidelines for an orthotic supply. The studies do not seem to be meaningful and universal due to the difficult ascertainability of pain. There is a need for further research here. Nevertheless, the authors of this review are of the opinion that the implementation of trunk orthoses is void of side effects and beneficial to patients. The modular systems seem to have an advantage as well as higher patient satisfaction.

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Evidence-based interventions (EBIs) for youth with autism spectrum disorders (ASD) are rarely found in community settings where most youth with ASD receive services. Implementation research designed to help bridge this gap is needed. However, efforts to implement EBIs in community settings face a number of barriers. The main purpose of this article is to illustrate how making EBIs more flexible and integrative may help improve their utility and may increase their uptake by stakeholders in community mental health and school settings. We conclude with an example of a modular, stepped-care program that might help bridge the science-practice gap in the ASD field by combining elements of a number of existing EBIs into a single, flexible intervention.

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