Improving Quality of Care in Child Mental Health Service Settings

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.

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