C-FIT adolescent diversion program: A behavioral intervention pilot test for delinquent offenders

Abstract

The Community-Family Integration Teams (C-FIT) diversion program was developed to address behavioral and mental health treatment for justice-involved adolescents. The C-FIT pilot study, implemented in Jordan, aimed to (1) evaluate intervention fidelity and (2) assess intervention effectiveness. Adolescent males (n = 19) and their families participated in the C-FIT study. Pre and post data were collected through interviews and standardized instruments. The mean fidelity score was 31.4 out of 46 (68%), indicating reasonable fidelity. Data suggest declining levels of internalizing problems. The C-FIT program holds promise for improving adolescent mental health outcomes and decreasing recidivism youths who are at risk of detention center placement.

Keywords

Adolescent behavioral intervention diversion program fidelity intervention research juvenile justice mental health

Introduction

Delinquent adolescents suffer a disproportionate burden of behavioral and mental health problems and greater disconnection from positive peers, school, and employment when compared with community samples. Studies in both the United States and internationally show that whereas 13–21 percent of youth under the age 18 years in the community will experience a mental disorder, up to 70 percent of detained and incarcerated youths have a diagnosable mental health problem (ATLAS, 2005; Karam et al., 2006; Kessler et al., 2007; Merikangas et al., 2010; Perou et al., 2013; Shaffer et al., 1996; The WHO World Mental Health Survey Consortium, 2004). In studies conducted in the US and across the world, approximately 20 percent of detained youths meet diagnostic criteria for a depressive disorder, 20–30 percent meet the criteria for anxiety disorders, 40 percent have a substance use disorder, and 30–50 percent display serious symptoms of oppositional defiant and conduct disorders (Abram et al., 2004, 2008a; Fazel et al., 2008; Sawyer et al., 2010; Teplin et al., 2002; Wasserman et al., 2002, 2010). Time in institutions, or dose effect, can worsen adolescent mental health symptoms and behavioral problems (Gatti et al., 2009; Loughran et al., 2009; Schwalbe et al., 2013a; White et al., 2010) and lead to a dramatic increase in the risk of long-term criminal justice involvement (Gatti et al., 2009). Incarceration also stigmatizes youths (Schwalbe et al., 2013b), creating significant burden on youths and their families and making it difficult to establish pro-social patterns of involvement in school, community, and relationships (Bernburg et al., 2006). Furthermore, untreated emotional and behavioral problems can hinder reintegration into the community, exacerbating antisocial behavior, criminality, and risk of recidivism (Belenko and Dembo, 2003; Pullmann et al., 2006).

Nascent research on diversion programs suggests that providing mental health services to delinquent adolescents in home-like settings can improve youth and system outcomes (Cuellar et al., 2006; Hamilton et al., 2007). However, study after study shows that many justice-involved youths do not receive treatment for their emotional and behavioral disorders regardless of whether they are incarcerated or monitored in the community via diversion or probation programs (Abram et al., 2008b; Mulvey et al., 2007; Teplin et al., 2005; Wasserman et al., 2009). The problem of low participation rates is compounded by the uneven distribution of treatment resources across regions. In many juvenile justice settings, treatment resources are simply unavailable. Moreover, these services and the human resources needed to provide treatment are often unevenly distributed, with large proportions of available mental health professionals located in high-resourced urban centers. Thus, there is an urgent need to develop community-based diversion programs that are transportable to low-resource communities and countries that have underdeveloped mental health and family service systems to address the complex needs of delinquent adolescents and their families.

The Community-Family Integration Teams (C-FIT) diversion program has been developed to address the complexities of providing treatment to justice-involved adolescents in low-resource communities. C-FIT was developed in 2011 and pilot tested through a United Nations Children’s Fund (UNICEF)-funded university–government–community research partnership in Jordan. The C-FIT intervention is designed to disrupt negative developmental trajectories among delinquent adolescents and to improve outcomes in the areas of mental health and behavioral problems, recidivism risk, and improved family and community engagement. C-FIT is a new integrative intervention that draws on three evidence-based interventions (task-centered case management [TC], parent management training [PMT], and cognitive behavioral therapy [CBT]) to improve the emotional and behavioral functioning of delinquent adolescents who are diverted from juvenile justice incarceration into home-based treatment. Individually, each of these intervention components has been found to be efficacious in the treatment of the multiple problems and risks confronted by youth in juvenile justice systems (Butler et al., 2006; Hofmann et al., 2012; Kazdin, 1997; Kazdin et al., 1992; Reid, 1997). In addition, the C-FIT program manual focused on simplifying service delivery to accommodate low-resource countries and communities where the human services workforce has relatively low levels of training in counseling-based intervention approaches such as social work and psychology (Vikram et al., 2008; World Health Organization [WHO], 2009).

Jordan is an optimal setting to pilot this intervention. As in other low- and middle-income countries (LMICs) around the world (United Nations Children’s Fund [UNICEF], 2007a, 2009), over 70 percent of incarcerated Jordanian youth are in pre-trial detention (Schwalbe et al., 2013a), with 75 percent detained for minor offenses such as fighting, theft, or behavioral problems (UNICEF, 2007b, 2007c). In Jordan, adolescents placed in detention centers exhibit similarly high rates of many psychosocial problems, including 30 percent with depression, 27 percent with aggression, 24 percent with suicidal ideation, and 24 percent with posttraumatic stress disorder (PTSD; Schwalbe et al., 2013a). Similar to other LMICs, Jordan has few agencies providing community-based mental health services and a limited number of trained mental health professionals (National Mental Health Team, 2010; National Steering Committee for Mental Health, 2011; WHO & Jordanian Ministry of Health, 2011). For example, in Jordan less than 3 percent of governmental health expenditures are directed to family mental health (National Mental Health Team, 2010), and of the 64 outpatient mental health facilities in the country, only three are dedicated to the treatment of children and adolescents (Hijiawi et al., 2013; National Mental Health Team, 2010; WHO & Jordanian Ministry of Health, 2011). However, Jordan is among the few LMICs in the Middle East with a national mental health policy (ATLAS, 2005; Minister of Public Sector Development, 2008; National Mental Health Team, 2010), and a National Action Plan with provisions for community-based services for youths within the juvenile justice system. Consistent with these policy frameworks, the Jordanian government and our investigative team established a collaborative relationship with the support of UNICEF to develop, evaluate, and institutionalize diversion for delinquent youths. The low-resource context and nascent mental health and family services systems in Jordan positions this study to contribute to the scientific knowledge on the efficacy of an innovative program to reduce conduct problems and criminality in a high-risk population with implications for other low-resource countries and communities in the US.

The purpose of this feasibility pilot study was to assess the implementation of the C-FIT program with delinquent adolescents in Jordan. The specific aims of the study are as follows: (1) to evaluate whether the intervention can be implemented with fidelity by staff with low levels of pre-service training, and (2) to conduct a preliminary assessment of the effectiveness of the C-FIT program on adolescent diversion and mental health outcomes.

The C-FIT intervention

The 16-week C-FIT program targets adolescents’ behavioral and mental health needs by altering causal pathways that are common to the complex clinical profiles of delinquent adolescents. The C-FIT program integrates three evidence-based interventions: TC, PMT, and CBT. The TC component includes a structured approach to collaborative case planning that addresses needs related to gaps in community support and problems in living not addressed by the other intervention components. TC focuses on issues associated with chronic delinquency, such as negative peer involvements and school success (Pazaratz, 2000; Reid, 1997; Rooney, 2013). PMT facilitates parents in strengthening their monitoring and supervision activities by learning parenting strategies based on principles of operant learning (Kazdin, 1997; Kazdin et al., 1992). CBT is an evidence-based treatment that targets a variety of emotional and behavioral disorders (Butler et al., 2006; Hofmann et al., 2012). CBT teaches clients how to respond to problems with positive coping strategies, to apply problem-solving strategies, and to evaluate cognitive appraisals of potential problems (Beck, 1976, 1997, 2011; Benjamin et al., 2011; David-Ferdon and Kaslow, 2008; Kendall, 2011; Silverman et al., 2008).

Figure 1 presents the C-FIT Program Model comprised of three components: intervention activities, intermediate outcomes, and distal outcomes. The C-FIT intervention targets the reduction of mental health and behavioral problems, and facilitates successful community integration for court-involved adolescents (aged 12–17 years) engaged in a diversion program. The C-FIT intervention exerts changes on malleable mediators (e.g. coping skills, family functioning) that in turn can reduce the risk of mental health, behavioral, and substance problems. There are three parts to the C-FIT intervention. Part I, the comprehensive assessment, identifies the adolescent’s needs (e.g. mental health problem, risk, and protective factors) through interviews conducted with the family and with the adolescent. Part II, determination of need and intervention intensity, evaluates the adolescent’s level of need as high or low by extracting standardized scores measured across four core behaviors and mental health symptoms (depressive mood, anxiety, rule-breaking behavior, physical aggression toward others) from the assessment. Need determination is guided by the risk-need-responsivity (RNR) model in criminal justice that states intensive diversion interventions are more effective when targeting higher-risk youth, whereas intensive interventions with low-risk youths can have no effect or be iatrogenic (Andrews and Bonta, 2010; Bonta et al., 2008; Dowden and Andrews, 2000; Lowenkamp et al., 2006; Vieira et al., 2009). Thus, a youth whose score is high is assigned to a high-need group and receives the full C-FIT program, whereas low scores across these areas place the youth’s need as low and therefore warranting the base C-FIT intervention. Part III, the full C-FIT intervention program, is a 16-week manualized program of intensive case management and treatment that is delivered by two-person teams trained in the C-FIT program, consisting of a social worker from a community-based non-governmental organization (NGO) and a probation officer (also known as a behavioral observer in Jordan) from the government’s Ministry of Social Development.

Figure 1.

C-FIT diversion program model.

Methods

Participants

The sample for this study included 19 adolescent males (aged 13–17 years) and their families who participated in the C-FIT program pilot. The adolescents were referred to the program by judges following an adjudication of delinquency based on their judgment of youth and family amenability to treatment. Adolescents were eligible if this was their first or second offense; those charged with violent offenses were excluded.

Data were collected through case file extraction and interviews with adolescents and the families using standardized instruments. Baseline data (e.g. demographics, mental health, and legal history) were extracted through case file review of the initial comprehensive assessment conducted by C-FIT program staff. Follow-up interviews were conducted after the youth had completed the C-FIT program (4 months post-baseline); the interviews were administered in Arabic by Jordanian research assistants who were extensively trained on data collection protocols. All procedures for the study received Institutional Review Board (IRB) approval both in Jordan and the US.

Measures

Demographic and other information about the youths and families were obtained from comprehensive assessments completed at intake by the implementation teams. Assessment information extracted from the comprehensive assessments includes gender, age, legal history, and family socio-economic factors (e.g. parent’s employment and education status).

Two areas of adolescent outcomes were measured: recidivism and mental health. Recidivism was measured as a dichotomous variable based on whether or not the youth was rearrested at any point after diversion to the C-FIT program. The mental health and behavioral functioning of the youth at intake and at program completion were evaluated using the Arabic language translation of the Youth Self Report (YSR; Achenbach, 1991; Achenbach and Rescorla, 2001; Yunis et al., 2007). The YSR includes ratings for 112 behaviors on a three-point scale (0 = not true, 1 = sometimes true, 2 = very often true). The YSR includes two major scales: internalizing problems (α = .793) and externalizing problems (α = .859). These scales are further divided into subscales corresponding to an internalizing symptom cluster (e.g. anxious/depressed, α = .651; withdrawn/depressed, α = .374) and an externalizing symptom cluster (rule-breaking, α = .775; aggressive behavior, α = .774). Two types of scores are utilized in this study: the total scale score and threshold scores for borderline/clinical level problems. The YSR was completed during the initial assessment interview (n = 19) and at the 4-month follow-up interview (YSR, n = 15). Change scores for individual youths were calculated by subtracting YSR subscale follow-up scores from youth baseline scores. Change scores greater than zero suggest fewer emotional/behavioral problems at follow-up compared to baseline.

Fidelity of program component delivery was measured using a project derived fidelity checklist to indicate the degree to which the program was implemented as planned. The checklist provides a comprehensive account of the C-FIT intervention steps completed by practitioners with youth and their families. Fidelity of implementation teams to the program design was assessed via a systematic file review by program quality assurance officers. In the file review, each step of the program was assigned points ranging from 0 to 2 (0 = incomplete, 1 = partially complete, 2 = complete). For this evaluation, fidelity ratings of three C-FIT components were analyzed: (1) completion of the task-centered worksheet (12 points possible), (2) completion of the PMT worksheet (22 points possible), and (3) completion of the psycho-education worksheet (12 points possible). Across these three worksheets, the total possible fidelity score is 46 points.

Analytic plan

The analytic plan included descriptive and bivariate analysis conducted using Stata 12.0 (Stata Corporation, College Station, TX). Intervention fidelity was assessed using descriptive analysis and t-tests to assess whether implementation fidelity improved over time. Baseline and follow-up results for YSR subscales were used to evaluate youth mental health outcomes. Scatterplots of YSR change scores were used to examine change in mental health symptoms over time from baseline to follow-up.

Results

Demographics

On average, adolescents participating in the C-FIT pilot (n = 19) were 16 years old (M = 15.8; standard deviation (SD) = 1.1; range: 13–17 years). All adolescents were males, reflecting the population in detention within Jordan, as the few female adolescents in conflict with the law are placed in a secure group home setting rather than traditional detention centers. This was the first arrest for 66 percent (n = 12) of the sample; the remaining third (n = 7) of adolescents had one prior arrest. Limited family education and employment seems to characterize this sample, with only half of all families reporting at least one parent working part- or full-time (n = 7), and half of all parents attaining a high school diploma or greater (n = 8). Correspondingly, family financial status ratings for this sample were low, with 10 families (55%) reporting that they were ‘barely making it’ or that they ‘cannot make ends meet’.

Implementation fidelity

This study sought to evaluate whether the intervention can be implemented with fidelity by staff with low levels of pre-service training. C-FIT providers were seconded from existing governmental and non-profit staff experienced in working with adolescents in detention. None of the intervention providers had advanced degrees (e.g. social work or psychology). C-FIT providers received specialized training and supervision in the delivery of C-FIT intervention protocols. Training was provided by the C-FIT development team. Each provider training course lasted 5 days and focused on learning the intervention manual and skill-building, including role-plays. Each provider received weekly supervision from the C-FIT development team.

Table 1 shows the results of the fidelity analysis. The mean overall fidelity score across the pilot was 31.4 out of a possible 46 (68%), indicating that the providers maintained reasonable fidelity. Fidelity sub-scores were also assessed across the three components of C-FIT, specifically the TC score was 9.8 out of 12 (82%), the PMT score was 13.7 out of 22 (62%), and the CBT score was 7.9 out of 12 (66%). This indicates that some components of the program (TC) seem to be offered with higher fidelity than others (PMT, CBT), offering targeted opportunities for ongoing provider supervision and training.

Table 1.

Fidelity ratings of the implementation team by diverted youth cohort.

	Total possible score	Total pilot group (n = 19)	Early pilot group (n = 9)	Late pilot group (n = 10)	t-test
Task-centered worksheet	12	9.8 (3.7)	8 (1.5)	11.4 (.6)	t = 2.20*
Parent management training worksheet	22	13.7 (8.0)	7.8 (2.6)	19.1 (.8)	t = 4.31***
Psycho-education worksheet	12	7.9 (3.9)	6.2 (1.6)	9.4 (.6)	t = 1.9*
Total fidelity score	46	31.4 (13.6)	22 (4.5)	39.9 (2.0)	t = 3.80***

p < .05; and ***p < .001.

We also examined whether fidelity improved over time and training by separating the pilot into two groups: (1) early pilot group (n = 9), encompassing the first nine adolescents referred to the program and (2) late pilot group (n = 10), consisting of the next 10 adolescents entering the program. In all measures, the late pilot group received higher fidelity ratings than the early pilot group. Indeed, these differences are large and all statistically significant (see Table 1).

Preliminary program outcomes

This study conducted a preliminary assessment of the effectiveness of the C-FIT program on adolescent recidivism and mental health outcomes. Overall, 16 percent of all adolescents experienced a detention center admission during the period following their referral to the C-FIT program. The timing of the recidivism was calculated by subtracting the date of C-FIT program referral from the date of subsequent detention center placement. In this sample, the re-offenses occurred at an average of 111 days following initial program referral. Of those youths who did not reoffend during the program period, their average length of observation (evaluation end date minus date of C-FIT referral) was 208 days. Because of the relatively short follow-up period for all youths in the study, ranging from approximately 3–14 months, these findings are indicative of the short-term effects of the C-FIT diversion program on recidivism.

When examined across time (baseline to follow-up), data for diverted youths suggest declining levels of internalizing problems (26% vs 13% at borderline/clinical levels) and increasing levels of clinically significant externalizing (10% vs 20% at borderline/clinical levels). Change over time in mental health symptoms for the diverted youths are examined using baseline follow-up change scores as presented in Table 2. Overall, change scores suggest stability in internalizing problems from baseline to follow-up (median change score = 0), and slight increases in externalizing problems from baseline to follow-up (median change score = −1). Across most subscales, more youths reported increasing problem scores (i.e. change score <0).

Table 2.

C-FIT diversion program change scores by mental health score at assessment.

	Low score (⩽25%)								Mid score (>25% and <75%)								High score (⩾75%)
	N	M (SD)	Med		Range	N < 0	N = 0	N > 0	N	M (SD)	Med		Range	N < 0	N = 0	N > 0	N	M (SD)	Med		Range	N < 0	N = 0	N > 0
Internalizing
Total	6	−5.2 (4.1)	−4.5	−12	0	5	1	0	6	1.3 (5.2)	.5	−6	10	1	2	3	3	3.0 (2.6)	4	0	5	0	1	2
(1)	4	−4.3 (3.6)	−3.5	−9	−1	4	0	0	8	−.9 (2.4)	−1	−5	3	5	1	2	3	4.3 (3.2)	3	2	8	0	0	3
(2)	6	−1.8 (1.9)	−2	−5	1	5	0	1	5	−1 (2.0)	0	−4	1	2	2	1	4	3.0 (2.6)	3	0	6	0	1	3
Externalizing
Total	4	−7.8 (3.5)	−7.5	−12	−4	4	0	0	7	−1.1 (3.8)	−1	−8	3	4	0	3	4	6.0 (7.5)	6	−3	15	1	0	3
(3)	5	−3.2 (2.9)	−3	−6	1	4	0	1	4	−1.5 (2.4)	−1.5	−4	1	2	1	1	6	1.3 (4.3)	0	−3	9	3	0	3
(4)	4	−2.8 (.5)	−3	−3	−2	4	0	0	6	−.3 (4.3)	0	−6	6	3	0	3	5	2.4 (1.8)	2	0	5	0	1	4

(1) Anxious Depressed Subscale; (2) Withdrawn Depressed Subscale; (3) Rule-Breaking Subscale; (4) Aggression Subscale.

Change scores are calculated as the baseline level minus the follow-up. Therefore, negative values mean higher scores at follow-up.

To better understand mental health outcomes, further investigation was conducted by examining the relationship between severity of mental health scores at assessment and change scores. The sample was divided into three groups based on distribution of mental health scores at assessment (High: ⩾75%; Mid: >25% and <75%; Low: ⩽25%). Youth with high mental health scores at assessment showed lower scores post-intervention for all scales (internalizing, anxious depressed, withdrawn depressed, externalizing, and aggression) except rule-breaking. In contrast, youth with low scores at assessment were found to have increased mental health scores across all scales following the intervention. Youth in the mid-range had mixed outcomes. Figure 2 illustrates the association of the internalizing and externalizing change scores over time. This figure suggests that change scores were higher for youths who reported greater levels of emotional and behavioral problems at baseline.

Figure 2.

C-FIT diversion program: association of YSR internalizing and externalizing changes scores with baseline levels.

Discussion

This study assessed the implementation of the C-FIT diversion program as a therapeutic home-based alternative to incarceration for delinquent adolescents. Due to the preliminary nature of the pilot study, caution must be taken in interpreting findings. An examination of the C-FIT program component completion to enhance fidelity found that through ongoing monitoring and training fidelity can be achieved by staff with low levels of prior experience and/or training. General trends indicate that the C-FIT program may hold promise for improving adolescent recidivism and mental health outcomes specifically for adolescents with more severe mental health problems.

Developing a sustainable fidelity system to track, monitor, and provide feedback for ongoing training and supervision is essential to any intervention (Bond et al., 2000; Borelli et al., 2005; Gearing et al., 2011a; Perepletchikova et al., 2007), particularly for interventions conducted in low-resource communities where staff are likely to have limited prior mental health training. The C-FIT quality assurance system included sessional fidelity tracking sheets with ongoing monitoring of fidelity data by designated quality assurance officers. The fidelity rating system permitted quality assurance officers to make informed judgments about the quality of program implementation (Dusenbury et al., 2003; Gearing et al., 2011a) and to provide feedback (Perepletchikova and Kazdin, 2005) to implementation teams on a case-by-case basis to improve program delivery to all children and their families. In this study, regular fidelity monitoring and feedback led to an increase in fidelity ratings over the course of the trial.

Accurately assessing fidelity within a program is also essential to all stages of outcome research (Gearing et al., 2011b; Perepletchikova et al., 2007). Without measuring fidelity it is difficult to determine whether the independent variable was effectively manipulated as planned (Bond et al., 2000), rendering results impossible to interpret in terms of whether unsuccessful outcomes reflect model failure or implementation failure (Mowbray et al., 2003). Furthermore, failure to adhere to intervention protocols undermines intervention effectiveness and negatively affects the accuracy of clinical case evaluations (Gearing et al., 2011b).

Recidivism is a critical public safety outcome for diversion programs as well as a key indicator of youth community functioning. Data from diversion programs worldwide suggest that recidivism rates average between 30 and 40 percent for both diverted youths and youths referred for full juvenile justice processing (Schwalbe, 2007; Schwalbe et al., 2012). In Jordanian detention centers, approximately half of detained youths have at least one prior detention center placement, which reflects a 50 percent recidivism rate (Schwalbe et al., 2013a). Although these rates are similar in magnitude, these findings are often interpreted as supportive of diversion programs as they indicate that a majority of youth in conflict with the law can be managed successfully without deep involvement with the juvenile justice system. The pilot study found that only 16 percent of C-FIT diverted youth had been rearrested by follow-up. The available data suggest programs affect recidivism. Longer follow-up times with a larger sample are needed to determine whether this is indeed an enduring pattern.

Findings indicate that C-FIT was beneficial to participant mental health outcomes for youth with higher baseline levels of mental health symptoms experiencing greater improvements. At first examination, results of the intervention on mental health are mixed, with boys showing decreased internalizing problems but increased externalizing problems. Further examination revealed that youth with greater mental health problems at assessment showed general improvement in their mental health scores, whereas youth with low initial problems were found to have worse scores following the intervention. Three possible explanations underlie these findings. First, findings may be an artifact of the regression to the mean phenomena. Second, they could represent uneven implementation quality as it is noted that fidelity increased substantially over the course of the trial. Third, these findings suggest that the C-FIT program may be more suitable for youths with higher levels of mental health problems. This explanation accords with the growing research support for the RNR model in criminal justice, whereby intensive diversion programs are more effective when targeting higher-risk youth but can lead to iatrogenic effects for lower-risk youths (Andrews and Bonta, 2010; Bonta et al., 2008; Dowden and Andrews, 2000; Lowenkamp et al., 2006; Vieira et al., 2009). Confirmation of this finding and its underlying mechanisms awaits further experimental studies with larger samples.

Common to pilot studies, this study is limited by the small sample size of adolescent males. We were unable to assess four participants who were lost to us at follow-up, which further limits the analysis. Therefore, caution is urged in interpreting these preliminary findings. As this study utilized a pre and post design without an additional follow-up time point, we are unable to draw conclusions about the long-term effects of C-FIT on emotional and behavioral problems. Further assessment of the C-FIT intervention is needed, including experimental designs with a larger sample size to assess for causality between the intervention and adolescent outcomes. Increased sample size would also facilitate a nuanced analysis of mechanisms of change to determine which elements of the intervention improve which outcomes. Although this study measured fidelity of program component delivery, a more comprehensive independent assessment of practitioner quality is recommended for future research.

A disproportionate number of adolescents in juvenile correction settings suffer from mental health and behavioral problems. Research has demonstrated that many justice-involved youths do not receive treatment for their emotional and behavioral disorders regardless of being incarcerated or monitored in the community via probation programs (Abram et al., 2008b; Mulvey et al., 2007; Teplin et al., 2005; Wasserman et al., 2009). The problem of low participation rates is compounded by the uneven distribution of treatment resources across regions. In many juvenile justice settings, treatment resources for problems such as depression, anxiety, and conduct are simply unavailable. Moreover, entire communities can be underserved, particularly low-resourced countries and regions, such as Jordan and rural areas of the US, where treatment resources may be unavailable or care systems are ill-equipped to provide mental health care to adolescents. C-FIT has been developed to address these complex needs of delinquent adolescents and their families in low-resource communities and countries with underdeveloped service systems. It is recommended that intervention research should not only assess for fidelity, but also assess whether agencies have the resources available to effectively ensure intervention fidelity, such as having sufficient time and staffing (Gearing et al., 2011b). Overall, this pilot study found that the C-FIT intervention could be delivered with high fidelity in low-resourced, under-trained communities and that the intervention benefitted adolescent males with higher levels of initial mental health problems.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This study was supported through a Project Co-operation Agreement with UNICEF.

Author biographies

Robin E Gearing is an Associate Professor and the Director of the Center for Mental Health Research and Innovations in Treatment Engagement and Services (MH-RITES Center) at the Graduate College of Social Work, University of Houston. Dr. Gearing’s research focuses on improving the mental health outcomes of adolescents with serious mental illnesses, and their families. His research is driven by an interest in informing and improving adolescent engagement and adherence to empirically-supported psychosocial and medication treatment, and developing evidence-based interventions.

Craig SJ Schwalbe is an associate dean and associate professor with the Columbia University School of Social Work. His research focuses on the utilization of best practice in juvenile justice agencies to minimize the use of detention and custodial sentences for adolescents in conflict with the law.

Michael J MacKenzie is a social worker and developmental psychologist and serves as the Chancellor’s Scholar for Child Well-Being and Associate Professor of Social Work and Pediatrics at Rutgers, The State University of New Jersey. His area of research and practice focuses on early child development, stress physiology, and the experiences of children in child welfare systems.

Rawan W Ibrahim is a lecturer at the German-Jordanian University and an alternative care consultant for UNICEF. In addition to implementation science and the development of community-based programs in developing economy contexts, her research interests include preparation and post-care support of youth transitioning from substitute care to adulthood. Of particular interest are subgroups such as those separated from families at birth and at-risk young women.

Shadi Bushnaq is a freelance consultant with organizations such as UNICEF in Jordan. His work focuses on building capacities of government and community-based para-professional social workers in psychosocial interventions for children in alternative care and youth in conflict with the law. Previously, he served as Clinical Director and Program researcher at Columbia Middle East Research Center for the Community-Family Integration Teams program.

Kathryne B Brewer is an Assistant Professor in the Department of Social Work at the University of New Hampshire. Her program of research focuses on adolescent resilience, including methods of strengthening self-regulation, increasing engagement in social services, and promoting positive outcomes in adolescents involved in child welfare and criminal justice systems in both U.S. and international contexts.

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