Treatment Beliefs and Techniques of Clinicians Serving Child Maltreatment Survivors

Abstract

A significant focus in the child maltreatment field is greater dissemination and implementation of evidence-based treatments (EBTs). Research has attempted to identify attitudes toward EBTs and training experiences that predict clinicians’ use of EBTs; however, these findings have yielded mixed results. This study reports on the results of a nationwide (United States) sample of 256 clinicians serving child maltreatment survivors, who completed questionnaires assessing beliefs about the clinical process, treatment technique selection, and attitudes toward EBTs. Psychometric data are presented on two new scales. The first scale examines clinicians’ beliefs about two components of the clinical process: (1) the extent to which treatment should be structured/directed by the clinician and (2) children’s verbal capacity to discuss traumatic events. The second scale assesses clinician-reported selection of various treatment techniques and contains four subscales: Cognitive–Behavioral, Play/Experiential, Psychodynamic, and Uncommon. Using these scales, a series of analyses were performed to determine which attitudes, beliefs, and training variables were associated with the selection of treatment techniques. After controlling for the impact of other variables, significant associations between the two clinical process beliefs and cognitive–behavioral and play/experiential techniques utilization were observed. Implications of these results for increasing implementation of EBTs with child maltreatment survivors are discussed.

Keywords

child maltreatment evidence-based treatment dissemination implementation

The past 20 years have witnessed a significant emphasis in the mental health field on the development, dissemination, and implementation of treatment techniques and protocols demonstrated in clinical trials to create positive change in presenting symptoms, interventions often referred to as evidence-based treatments (EBTs; Kazdin, 2008). Numerous agencies of the U.S. federal government now maintain databases of interventions with demonstrated efficacy, and other professional and governmental organizations have likewise developed similar catalogs of interventions. This trend is especially pronounced in the field of child maltreatment. For instance, the U.S. federal government has invested significant financial resources toward increasing implementation of EBTs through funding for the National Child Traumatic Stress Network and other initiatives (Pynoos et al., 2008). A current focus in the child maltreatment field and in the mental health field, in general, is exploring ways to increase the implementation of EBTs by practicing clinicians; however, numerous factors may impact a clinician’s decision whether to implement EBTs and their component techniques.

Structure of Clinical Sessions and EBTs

The majority of EBTs for childhood maltreatment, such as Trauma-Focused Cognitive–Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) and Parent–Child Interaction Therapy (PCIT; McNeil & Hembree-Kigin, 2010), tend to incorporate cognitive–behavioral techniques. However, EBTs from other theoretical perspectives, for instance, Child Parent Psychotherapy (CPP; Lieberman & Van Horn, 2005) or Motivational Interviewing (Miller & Rollnick, 2012), are also available and applicable to the child maltreatment field. Regardless of theoretical orientation, EBTs display some common characteristics. Primary among these similarities is a structured treatment approach where the goals and techniques of treatment are defined for the clinician in a manual or protocol, thereby enhancing consistency across clinicians in the delivery of the treatment and allowing for an examination of clinician fidelity to the model. Interventions impose varying levels of structure and flexibility within the protocols, but less structured EBTs still designate clinical techniques, sequences, and goals.

Much of the impetus for the attention paid to EBTs for child maltreatment is the result of a significant amount of research completed over recent years examining various treatment approaches for traumatic stress and related symptoms. Studies have repeatedly demonstrated superior treatment effects for interventions that focus on directly discussing and processing the trauma (i.e., trauma focused) when compared to nondirective approaches (Cohen, Mannarino, & Iyenger, 2011; Deblinger, Mannarino, Cohen, & Steer, 2006). These results were recently confirmed in a meta-analysis comparing trauma-focused and nondirective/unstructured treatment approaches (Cary & McMillen, 2012). Oftentimes, the primary presenting problem is external in nature and a parent-training intervention, such as PCIT, might be more appropriate. However, even when using a parent-training intervention, the clinician must remain trauma sensitive and a direct discussion of the trauma with the child and caregiver may be indicated (Lieberman & Van Horn, 2008).

Despite the empirical evidence of effectiveness and growing emphasis placed on EBTs by policy makers and funders, Allen, Gharagozloo, and Johnson (2012) found that nondirective approaches (e.g., art therapy, nondirective play therapy, and sand tray therapy) continue to be some of the most utilized treatments for cases of child maltreatment. Results also suggested that clinicians reported commonly receiving training in nondirective/unstructured approaches but rarely viewed them as evidence based. Similarly, other researchers have concluded that evidence-based techniques for childhood trauma and abuse are infrequently used in general community practice (Borntrager, Chorpita, Higa-McMillan, Daleiden, & Starace, 2013).

Opposition to the implementation of EBTs is to be expected, as the emphasis on directive approaches runs counter to the prevailing historical paradigms of clinical philosophy. Specifically, clinicians were trained for decades in the use of nondirective approaches that emphasize allowing the child to address the abuse or neglect in their own way at their own pace (e.g., Axline, 1947). In addition, nondirective approaches tend to emphasize clinical intuition, judgment, and experience, qualities many view as being minimized or disregarded by EBTs (Zeldow, 2009); however, this clinical reasoning may prompt clinicians to refrain from using EBTs or specific evidence-based techniques if they are deemed contraindicated (Olatunji, Deacon, & Abramowitz, 2009). In addition, empirical evidence suggests that the integration of trauma-specific curricula in graduate training programs, including training in EBTs, is generally lacking (Courtois & Gold, 2009; Sigel & Silovsky, 2011). Given these historical and contemporary approaches to treatment and the typical training received, it is understandable that evidence-based approaches that prescribe directive and specific techniques may be unappealing for many clinicians. To date, however, no identified studies examined the impact of clinicians’ attitudes regarding the degree of directiveness/structure of sessions on the selection of EBTs for treating maltreated children.

Attitudes Toward EBTs

Numerous variables appear to impact the implementation of EBTs in practice settings, such as administrative support and organizational culture (Glisson, et al., 2008; Schoenwald, et al., 2008); however, an often examined factor is the attitude of clinicians toward various aspects of the evidence-based approach, such as following a treatment manual or being open to the use of treatments developed by researchers. The assumption is that more favorable attitudes toward EBTs may prompt greater utilization of these interventions; however, results of studies are mixed regarding the degree to which more favorable attitudes toward EBTs translates into greater implementation of EBTs (Jensen-Doss, Hawley, Lopez, & Osterberg, 2009; Kolko, Cohen, Mannarino, Baumann, & Knuden, 2009). It is possible that more positive attitudes toward an evidence-based perspective exert an indirect influence on the use of EBTs through association with other factors important in the selection and use of EBTs. For instance, clinicians with more favorable attitudes toward EBTs appear more knowledgeable about and interested in EBTs (Allen, Gharagozloo, & Johnson, 2012) as well as more likely to value the results of randomized controlled trials, a keystone research procedure in the validation of an intervention (Allen & Armstrong, in press-a). Given these findings, attitudes toward EBTs are important considerations when examining the selection of treatment techniques.

Training Characteristics and EBTs

The association of one’s training characteristics and experiences with treatment practices and attitudes have received considerable attention. For instance, studies have demonstrated that those with cognitive–behavioral orientations self-report greater willingness to attend training and utilize EBTs (Nelson & Steele, 2007; Stewart, Chambless, & Baron, 2012). However, studies have generally failed to find other training characteristics (e.g., education level and professional discipline) to be associated with treatment technique selection (Allen, et al., 2012) or attitudes toward EBTs (Aarons, 2004). Nonetheless, these characteristics are important considerations worthy of additional study as one’s general approach to clinical practice is often formed during graduate training.

Objectives of the Current Study

The primary goal of this study was to examine the relationship between clinicians’ beliefs regarding the appropriateness of clinician-directed/structured sessions with treatment technique selection when working with maltreated children under the age of 13. However, no current scales were available to measure these constructs of beliefs or technique selection when working with maltreated children. As such, this study has three separate, but related, objectives: (1) report on the development and psychometric characteristics of a scale assessing clinician beliefs regarding whether treatment sessions should be primarily structured or unstructured, and another examining commonly utilized treatment techniques with maltreated children; (2) identify attitudes toward EBTs and training characteristics associated with these two new scales; and (3) ascertain the extent to which differences in technique selection were explained by beliefs regarding structured or unstructured sessions, attitudes toward EBTs, and training characteristics. The specified age range was defined because many of the EBTs for children (e.g., PCIT and CPP) are not appropriate for adolescent youth and much of the impetus for nondirective approaches is a perceived inability for younger children to discuss traumatic events.

Method

Participants

Data for the current study were collected as part of the Treatment Attitudes, Perceptions, and Practices for Neglected and Abused Children (TAPPNAC) project. TAPPNAC was a nationwide (United States) survey that asked clinicians working in community settings about their treatment beliefs, commonly utilized techniques, attitudes toward research and EBTs, and other related topics. Clinicians completed a web-based survey between May and October 2010. Data collection occurred in three waves. First, the National Children’s Alliance (NCA) sent an invitation e-mail through their ListServ to directors of children’s advocacy centers (CACs) throughout the United States and asked directors to forward the e-mail and weblink to clinicians working with their agencies. Two follow-up reminder e-mails were sent. Second, clinicians identifying themselves as mental health clinicians in the membership directory of the American Professional Society on the Abuse of Children received e-mail invitations soliciting participation directly from the research staff. Finally, the United States was stratified into four distinct geographical regions based on population estimates and an equal number of invitation e-mails were sent to general community settings (e.g., private practices and community mental health centers) in each region. A greater specification of the sampling methodology is reported in Allen and Johnson (2012) who estimated a response rate between 26% and 29%.

Of the 285 clinicians who responded to the survey, a total of 256 clinicians provided complete data for each of the measures included in the current study. The sample was overwhelmingly female (n = 220, 86%) of European ethnic heritage (n = 220, 86%), and the average age was 44.3 years (standard deviation [SD] = 12.5; range = 24–74). Most of the sample held a master’s degree as the highest level of education (n = 202, 79%), but a diversity of professional disciplines were represented (counseling: n = 98, 38%; social work: n = 91, 36%; and psychology: n = 53, 21%). Most of the clinicians were independently licensed (n = 210, 82%) and had an average of 13.2 years (SD = 9.8; range = 0–43) of clinical experience, with an average of 12.3 years (SD = 9.5; range = 0–43) serving children who experienced trauma. In all, 42% (n = 108) of the clinicians identified their primary theoretical orientation as cognitive–behavioral/behavioral, 30% (n = 77) endorsed an eclectic orientation, and 22% (n = 57) reported a psychodynamic or humanistic orientation. Approximately 54% (n = 137) of the sample was employed by agencies that exclusively serve maltreated children (i.e., CACs). Other community settings represented included private practices (24%) and community mental health centers (14%), among others. Employment setting (CAC or other agency) was examined in the following analyses to determine whether clinicians working in agencies exclusively serving maltreated children differ from those working in more general community settings.

Measures

Evidence-Based Practice Attitude Scale (EBPAS)

The EBPAS is a self-report measure of a clinician’s attitudes toward various aspects of EBT (Aarons, 2004). Respondents rate the degree to which they agree with 15 items on a Likert-type scale from 0 (not at all) to 4 (to a very great extent). Its four subscales are designed to assess respondents’ beliefs that EBP diverges from their own clinical approach (Divergence), their willingness to use new or innovative treatments (Openness), their willingness to use an intervention if it was intuitively appealing (Appeal), and their willingness to use an intervention if required to do so (Requirements). Scores for each subscale are obtained by calculating the average item score. Acceptable validity and reliability were demonstrated in a series of studies (Aarons, 2004; Aarons et al., 2010). In the current study, internal consistency estimates (Cronbach’s α) were adequate: Divergence = .64, Appeal = .73, Openness = .80, and Requirements = .90. It should be noted that an expanded version of the EBPAS is now available (EBPAS-50; Aarons, Cafri, Lugo, & Sawitzky, 2012) but was not published at the time data collection for this project was completed. The additional constructs assessed by the expanded EBPAS assess perceptions of the limitations of EBTs, the fit of EBTs with one’s practice, and logistical issues with the implementation of EBTs. These constructs appear distinct from the new scales developed for the current study.

Results

Objective 1: Specification of the New Scales

Beliefs About Session Structure Scale

The Beliefs About Session Structure Scale was developed to measure clinicians’ beliefs that treatment with children experiencing trauma should be directive/structured or nondirective/unstructured in nature. A series of 8 items were developed. The questions were written by a team of clinicians, researchers, and graduate students based on the recommended role of the clinician in the treatment process by different treatment approaches. Primary among these influences was whether the clinician or child should select activities of session and dictate the direction of treatment, the extent to which clinicians should encourage the child to discuss the trauma and the ability of children to verbally describe traumatic events. Clinicians were presented with the following instructions: “The following questions pertain to the treatment of a child who developed emotional and/or behavioral problems after experiencing psychological trauma. Please describe the extent to which you agree or disagree with each of the following statements.…” It should be noted that the broader word “trauma” was used as more specific terms such as “abuse” or “neglect” may result in clinicians not considering other relevant experiences (e.g., witnessing domestic violence and traumatic experiences occurring as a result of neglect). The clinicians were previously prompted that these questions related to the treatment of children aged 12 years or younger. The response options were a Likert-type scale ranging from 0 (strongly disagree) to 4 (strongly agree). A copy of the scale is provided in Appendix A.

Principal axis factor analysis (PAFA)

A PAFA with direct oblimin (i.e., oblique) rotation was performed. An examination of the Kaiser–Meyer–Olkin measure of sampling adequacy (i.e., 0.76) and Bartlett’s test of sphericity, χ²(28) = 374.98, p < .001, indicated that a structural analysis of the scale items would be appropriate. Initially, the results of the PAFA indicated that two factors had Eigenvalues greater than 1.0. Further, an examination of the scree plot clearly indicated a two-factor solution. The two rotated factors accounted for 51.65% of the total variance, with the communalities ranging from .22 to .50. Each of the 8 items had pattern and structure coefficients greater than .40. Factor 1 (5 items; labeled Clinician-Directed, α = .68) and Factor 2 (3 items; labeled Verbal Capacity, α = .66) were moderately, positively correlated (r = .34, p < .001). The pattern coefficients, communalities, means, and SDs for each of the 8 items are displayed in Table 1.

Table 1.

Pattern Coefficients, Communalities, Means, and Standard Deviations for the Beliefs About Session Structure Scale.

	Pattern coefficients
Item	Clinician-Directed	Verbal Capacity	h ²	M	SD
6. Discuss trauma in their own time	−.67	−.09	.50	2.85	.82
1. Directed by the child	−.56	.10	.28	2.49	.99
3. Clinicians direct treatment	.50	.05	.27	1.95	.89
8. Children should select activities	−.48	.03	.22	2.21	.77
2. Directed by clinician to discuss trauma	.46	.25	.36	2.22	.95
7. Possess adequate verbal ability to discuss trauma	−.07	.73	.50	2.15	.96
4. Children can discuss trauma when directed	.19	.58	.46	2.31	.92
5. Lack the verbal ability to discuss trauma	.01	−.56	.31	2.52	1.06

Note. SD = standard deviation; h ² = communalities. Pattern coefficients > .40 are displayed in boldface text (in descending order of size) and were used for interpretation of the factors.

Scale interpretation

As expected, the primary factor emerging from the scale (Clinician-Directed) assessed one’s belief in whether the clinician or child should primarily direct treatment. The total scale score was obtained by determining the mean item score for the scale. Questions 1, 6, and 8 of this scale were reverse scored so that a higher total score indicates a greater belief in clinician-imposed structure/directiveness. The mean score for the 5-item scale (M = 1.72, SD = .59) was slightly below the midpoint, indicating that clinicians, on average, endorse a slightly more nondirective/unstructured approach to treating children who experienced trauma.

Unexpectedly, a second factor emerged (Verbal Capacity) that appears to assess the clinician’s belief that a child is capable of verbally discussing his or her traumatic experiences. This factor includes questions that ask clinicians their beliefs regarding whether children possess adequate verbal skills to discuss trauma as well as their perception of the likelihood or ability of children discussing their experiences. As such, this subscale appears to provide an indication of the clinician’s belief that the average child is capable of verbally discussing a traumatic event if prompted by the clinician. It is possible that many clinicians interpret a child’s posttraumatic avoidance of trauma-related memories and discussions as indications that a child’s developmental ability or emotional distress prevents an active discussion of the trauma. Such beliefs might dissuade clinicians from implementing trauma-focused interventions. Question 5 of the subscale was reverse scored, resulting in a higher score reflecting a greater belief in a child’s ability to verbally discuss and describe their trauma. The mean score for the 3-item scale (M = 1.98, SD = .76) was almost precisely at the midpoint of the scale. This may reflect clinicians’ experiences and beliefs that some children can easily discuss the events while others display more difficulty. Alternatively, it may reflect clinicians’ uncertainty about whether children can discuss their experiences.

Treatment Techniques Scale

To ascertain the type of treatment techniques currently being used with child maltreatment survivors in general community settings, the Treatment Techniques Scale was developed. A panel of experts in the field of child maltreatment research and intervention identified various treatment techniques and protocols that are commonly used to treat abused and neglected children (see Allen et al., 2012, for a discussion of this process and the interventions identified). Treatment articles, books, manuals, and other materials that are associated with these treatment approaches were reviewed and individual techniques were identified. A team of researchers, clinicians, and graduate students reviewed the materials and constructed the questionnaire that ultimately contained 24 distinct treatment techniques from a variety of theoretical orientations (see Appendix B). Clinicians completing the questionnaire were provided the following instructions: “Please describe how likely you are to use each of the following techniques in a typical course of treatment with a child who developed emotional and/or behavioral problems after experiencing psychological trauma.…” As before, clinicians were instructed to consider these questions in the context of treating a child aged 12 years or younger. Clinicians responded to each item using a 5-point Likert-type scale ranging from 0 (not at all likely) to 4 (very likely).

PAFA

Several PAFAs with direct oblimin (i.e., oblique) rotation were performed. An examination of the Kaiser–Meyer–Olkin measure of sampling adequacy (i.e., 0.81) and Bartlett’s test of sphericity, χ²(276) = 2,053.77, p < .001, indicated that a structural analysis of the items would be appropriate. The results of the analyses indicated that six factors had Eigenvalues over 1.0, while the scree plot indicated three to six factors. Based on these data, individual factor-level content examinations of the three-, four-, five-, and six-factor structures, as well as theory and practice noted in the child maltreatment extant literature, four factors were rotated in the final solution, accounting for 49.39% of the variance. Pattern coefficients were greater than .40 for 17 of the 24 items. The communalities for the 24 items ranged from .09 to .72. The pattern coefficients, communalities, means, and SDs for each of the items are displayed in Table 2.

Table 2.

Pattern Coefficients, Communalities, Means, and Standard Deviations for the Child Trauma Practices Scale Items.

	Pattern coefficients
Item	Play/experiential therapy	Cognitive–behavioral	Uncommon	Psychodynamic	h ²	M	SD
1. Nondirective play therapy	.75	−.23	.12	−.07	.72	2.33	1.22
2. Sand tray	.74	−.08	.13	.11	.55	2.08	1.39
8. Puppets, dollhouses, pretend play	.62	−.03	.00	−.24	.57	2.91	1.07
6. Drawing as emotional expression	.58	.24	−.06	−.15	.48	3.25	.85
17. Directive play therapy	.43	.28	−.06	−.22	.38	3.41	.77
14. Nondirective supportive counseling	.40	−.05	.14	−.12	.27	2.51	1.02
16. Psychoeducation	.13	.74	−.01	.13	.52	3.45	.84
4. Teach coping skills	.13	.72	−.01	.14	.50	3.46	.79
7. Cognitive restructuring	−.07	.71	−.09	−.03	.51	3.07	.92
23. Trauma narrative	−.05	.53	−.09	−.03	.29	2.90	1.04
9. Caregiver behavioral management skills	−.18	.47	.19	−.02	.29	2.25	1.15
5. Use of touch	−.03	−.01	.72	−.01	.51	.91	1.00
20. Bottle-feed, rock, early development experiences	.04	−.08	.67	.06	.44	.77	1.00
11. Have caregiver physically hold the child	−.02	.03	.61	−.01	.38	.94	.84
22. Interpret drawings for emotional content	.15	−.11	−.00	−.75	.64	2.13	1.16
10. Analyze transference	−.06	−.11	.05	−.73	.51	1.58	1.13
18. Interpret play for emotional content	.20	−.12	.01	−.72	.66	2.26	1.16
3. Force eye contact	.06	.18	.37	−.08	.23	.66	.77
12. Reward appropriate behavior in session	−.26	.35	.15	−.23	.27	2.73	1.18
13. Interactive, collaborative storytelling	.27	.27	.11	−.16	.29	2.62	1.00
15. Bilateral stimulation	.02	−.03	.37	.05	.12	.71	1.15
19. Use projective techniques for treatment purposes	.05	.11	.02	−.39	.20	1.24	1.12
21. Sing songs, dance, music oriented	.25	.14	.29	−.15	.31	1.80	1.09
24. Animal, pet-assisted interventions	.03	−.04	.25	−.08	.09	1.21	1.19

Note. h ² = communalities. Pattern coefficients > .40 are displayed in boldface text (in descending order of size) and were used for interpretation of the factors. Items 3, 12, 13, 15, 19, 21, and 24 did not sufficiently load on any factor and are not recommended for usage with the subscales.

Scale interpretation

The four extracted factors were labeled as follows: (1) play/experiential therapy (α = .81; M = 2.55, SD = .81), (2) cognitive–behavioral (α = .76; M = 3.26, SD = .62), (3), uncommon (α = .70, M = .88, SD = .75), and (4) psychodynamic (α = .82, M = 1.99, SD = .98). Total subscale scores reflect the mean item score for the subscale. The highest scoring class of techniques was cognitive-behavioral, which clinicians reported being likely to use in the treatment of a child experiencing trauma. However, play/experiential techniques also appear commonly utilized by practicing clinicians with a mean score corresponding to a qualitative response between somewhat likely and likely. In addition, clinicians appear somewhat likely to implement psychodynamic techniques.

The relative frequency of clinicians’ reported use of groups of techniques was examined with paired-samples t-tests. As a group, clinicians reported being more likely to select cognitive–behavioral techniques than the other classes of techniques (all ts > 11.0, all ps < .001, all η²s > .32). Play/experiential techniques were more preferred than psychodynamic (t = 10.32, p < .001, η² = .29) and uncommon techniques (t = 16.94, p < .001, η² = .76). In addition, psychodynamic techniques were more preferred than uncommon techniques (t = 28.22, p < .001, η² = .53). By examining Table 2, one identifies five separate individual techniques with average scores greater than 3, indicating specific techniques that clinicians report being likely to use. These techniques include, in descending order of item score, teach coping skills (M = 3.46, SD = .79), psychoeducation (M = 3.45, SD = .84), teach caregiver behavioral management skills (M = 3.41, SD = .77), drawing as emotional expression (M = 3.25, SD = .85), and cognitive restructuring (M = 3.07, SD = .92). Consequently, whether examining item-level data or the extracted subscales, it appears that cognitive–behavioral techniques are selected with a significantly greater frequency than other treatment techniques.

Objective 2: Examining Correlates of the New Scales

Beliefs About Session Structure Scale

Training characteristics

The first two columns on the left of Table 3 show the means and SDs for the Clinician-Directed and the Verbal Capacity subscales as a function of theoretical orientation, professional discipline, education, and practice setting. Multivariate analyses of variance (MANOVAs) examined whether any training-related factors were associated with scores on the two beliefs subscales. Results for theoretical orientation were significant, Wilks’ λ = .86, F(4, 476) = 9.22, p < .001, with post hoc univariate analyses of variance (ANOVAs) suggesting significant differences for both the Clinician-Directed subscale, F(2, 239) = 17.17, p < .001, η² = .13, and the Verbal Capacity subscale, F(2, 239) = 6.95, p = .001, η² = .06. Post hoc between-group comparisons using the least significant difference (LSD) method found that CBT clinicians scored significantly higher on both subscales than the eclectic and psychodynamic/humanistic clinicians. No differences were present between the eclectic and psychodynamic/humanistic clinicians on either subscale. It should be noted that even though the cognitive–behavioral clinicians scored significantly higher than other clinicians on the Clinician-Directed subscale, their mean score was still on the nondirective/unstructured side of the scale. MANOVAs examining the association of professional discipline, Wilks’ λ = .95, F(4, 476) = .95, educational level, Wilks’s λ = .99, F(2, 247) = .21, and employment setting, CAC or another community setting, Wilks’s λ = .98, F(2, 253) = 2.19, were not related to beliefs.

Table 3.

Descriptive Data for BASS and Technique Scales.

	BASS: M (SD)		Technique Scales: M (SD)
Variable	Clinician-Directed	Verbal Capacity	Cognitive–Behavioral	Play/Experiential	Psychodynamic	Uncommon
Theoretical orientation
Cognitive–behavioral	1.96 (.62)^a	2.16 (.80)^a	3.45 (.48)^a	2.22 (.84)^a	1.69 (.98)^a	.73 (.63)^a
Humanistic/psychodynamic	1.46 (.56)^b	1.73 (.68)^b	2.88 (.87)^b	2.84 (.72)^b	2.22 (1.01)^b	.96 (.78)^ab
Eclectic	1.63 (.46)^b	1.89 (.71)^b	3.24 (.45)^c	2.79 (.63)^b	2.22 (.87)^b	.97 (.81)^b
Professional discipline
Counseling/counselor educ.	1.72 (.59)^a	1.94 (.69)^a	3.29 (.54)^a	2.80 (.69)^a	2.13 (.87)^a	1.05 (.83)^a
Social Work	1.70 (.59)^a	1.99 (.83)^a	3.37 (.59)^a	2.57 (.79)^b	2.13 (1.01)^a	.77 (.60)^b
Psychology	1.88 (.58)^a	2.08 (.78)^a	3.20 (.63)^a	2.10 (.82)^c	1.55 (.98)^b	.68 (.71)^b
Highest education degree
Master’s degree	1.72 (.58)^a	1.97 (.76)^a	3.32 (.60)^a	2.65 (.78)^a	2.07 (.97)^a	.90 (.75)^a
Doctoral degree	1.71 (.64)^a	2.04 (.76)^a	3.04 (.65)^b	2.27 (.77)^b	1.78 (.98)^a	.68 (.65)^a
Employment setting
Children’s Advocacy Center	1.79 (.62)^a	2.01 (.72)^a	3.31 (.64)^a	2.58 (.84)^a	1.87 (.99)^a	.75 (.73)^a
Other community setting	1.64 (.55)^a	1.93 (.81)^a	3.20 (.60)^a	2.52 (.76)^a	2.13 (.97)^b	1.02 (.76)^b

Note. BASS = Beliefs About Session Structure Scale. Values with the same superscript letters did not differ significantly.

Attitudes toward EBTs

The Clinician-Directed and Verbal Capacity beliefs were correlated with practice attitudes (see Table 4). A greater belief in Clinician-Directed sessions was positively correlated with a greater openness toward aspects of research-based treatments, such as using a manual, suggesting clinicians who are more directive are more open to EBTs. More directive clinicians saw less of a divergence between their own treatment techniques and those of EBTs. Finally, clinicians with a greater belief in the ability of children to describe their trauma were less likely to believe that EBTs diverge from their own practices. Of the total eight correlations computed, only these three significant results were obtained. It should be noted that the obtained statistically significant correlations yielded effect sizes generally considered between small and medium (Cohen, 1992). These results suggest that one’s clinical beliefs about directiveness and a child’s verbal capacity to discuss trauma were relatively distinct from attitudes toward EBTs.

Table 4.

Correlations Among Continuous Variables.

Variable	1	2	3	4	5	6	7	8	9	10
1. EBPAS: Requirements	—
2. EBPAS: Appeal	.29**	—
3. EBPAS: Openness	.20**	.55**	—
4. EBPAS: Divergence	−.27**	−.06	−.20**	—
5. BASS: Clinician-Directed	.09	.07	.22**	−.28**	—
6. BASS: Verbal Capacity	−.09	−.01	.08	−.15*	.34**	—
7. Techniques: Cognitive–Behavioral	.16*	.33**	.46**	−.31**	.46**	.31**	—
8. Techniques: Play/Experiential	−.01	.01	−.02	.12	−.41**	−.31**	.01	—
9. Techniques: Psychodynamic	−.08	−.02	−.04	.19**	−.26**	−.30**	−.01	.54**	—
10. Techniques: Uncommon	−.01	.01	.09	.23**	−.13*	−.15*	.01	.25**	.29**	—

Note. EBPAS = Evidence-Based Practice Attitude Scale; BASS = Beliefs About Session Structure Scale.

*p < .05. **p < .01.

Treatment Techniques Scale

Training characteristics

The last four columns of Table 3 show the means and SDs for the cognitive–behavioral, play/experiential, psychodynamic, and uncommon techniques as a function of theoretical orientation, professional discipline, education, and practice setting. MANOVAs were conducted to examine whether theoretical orientation was related to the four practice techniques. Theoretical orientation was related to clinicians’ reported technique selection, Wilks’ λ = .74, F(8, 472) = 9.58, p < .001. Post hoc univariate ANOVAs revealed significant differences for each of the scales: cognitive–behavioral, F(2, 239) = 17.53, p < .001, η² = .13, play/experiential, F(2, 239) = 18.41, p < .001, η² = .13, psychodynamic, F(2, 239) = 9.11, p < .001, η² = .07, uncommon, F(2, 239) = 3.2, p = 042, η² = .03.

Post hoc analyses using the LSD method demonstrated that cognitive–behavioral clinicians were significantly more likely to use cognitive–behavioral techniques than eclectic clinicians who were more likely to select these techniques than humanistic/psychodynamic clinicians. In addition, eclectic and humanistic/psychodynamic clinicians reported selecting more play/experiential techniques than cognitive–behavioral clinicians but did not differ from each other. A similar pattern was observed for psychodynamic techniques, with eclectic and humanistic/psychodynamic clinicians reporting a greater likelihood of selecting these techniques than cognitive–behavioral clinicians but not displaying noticeable differences between themselves. The uncommon techniques were rarely endorsed by any other three groups of clinicians. The only finding of note was a slightly greater likelihood of eclectic clinicians selecting these techniques than cognitive–behavioral clinicians. In summary, cognitive–behavioral clinicians reported a higher likelihood of choosing cognitive–behavioral techniques, humanistic/psychodynamic clinicians were more inclined to select psychodynamic and play/experiential techniques, and eclectic clinicians appear to find value in various classes of techniques. These results lend validity to the subscales of this measure.

Interestingly, educational level was related to technique selection, Wilks’ λ = .93, F(4, 245) = 4.61, p = .001, with differences observed on the play/experiential, F(1, 248) = 9.21, p = .003, η² = .04, and cognitive–behavioral techniques, F(1, 248) = 7.77, p = .006, η² = .03, but not for psychodynamic or uncommon techniques. LSD post hoc comparisons showed that master’s-level clinicians reported a greater likelihood of selecting both cognitive–behavioral and play/experiential techniques than doctoral-level clinicians. Professional discipline also was related to likely technique selection, Wilks’ λ = .84, F(8, 472) = 5.56, p < .001. Post hoc ANOVAs were significant for the play/experiential, F(2, 239) = 14.87, p < .001, η² = .11; psychodynamic, F(2, 239) = 7.59, p = .001, η² = .06; and uncommon techniques, F(2, 239) = 5.68, p = .004, η² = .05. As for the play/experiential techniques, clinicians with counseling degrees were more likely to consider these techniques than either social workers or psychologists, and social workers were more inclined to select play/experiential techniques than psychologists. Counselors and social workers displayed similar rates of psychodynamic technique selection, both of whom were more likely to select these techniques than psychologists. As for uncommon techniques, counselors were more open to their use than either social workers or psychologists. Significant variation between employment settings was observed, Wilks’ λ = .93, F(4, 251) = 4.88, p = .001. Clinicians in CACs differed from other community clinicians in the likelihood of selecting psychodynamic, F(1, 254) = 4.8, p = .029, η² = .02, and uncommon, F(1, 254) = 8.5, p = .004, η² = .03, treatment techniques. Specifically, CAC clinicians reported less likelihood of selecting both types of techniques than their counterparts in other community settings. No differences were observed for cognitive–behavioral or play/experiential techniques.

Attitudes toward EBTs

Correlations were examined between clinician attitudes toward EBTs and technique selection. As shown in Table 4, each of the four attitude types was associated with the likelihood of choosing cognitive–behavioral techniques. These results suggest that clinicians who are more open to EBTs and view them as compatible with their own approaches are more likely to select cognitive–behavioral techniques for treatment. None of the attitude types correlated with the selection of play/experiential techniques; however, a greater perception of EBTs as diverging from one’s own approach was related to a greater likelihood of selecting psychodynamic and uncommon techniques.

Beliefs regarding structure and verbal capacity

Table 4 also shows the correlations between the belief and technique measures. A greater belief in structured sessions was positively correlated with the selection of cognitive–behavioral techniques and negatively correlated with the selection of play/experiential, psychodynamic, and uncommon techniques. Similarly, a greater belief in the ability of children to verbally describe traumatic experiences was positively correlated with the likelihood of choosing cognitive–behavioral techniques and negatively correlated with the reported selection of play/experiential, psychodynamic, and uncommon techniques. With the exception of analyses involving uncommon techniques, the observed associations are generally considered between medium and large in strength (Cohen, 1992).

Objective 3: Explaining Variance in Treatment Technique Selection

A series of simultaneous regression analyses was performed to determine which variables remained predictive of technique selection once other associated variables were controlled and to ascertain the total variance collectively explained by the group of correlates. Each regression equation included the same predictor/independent variables to allow for comparison of results across technique classes. All predictor variables identified above as related to technique selection were included in the analyses: theoretical orientation, educational level, professional discipline, employment setting, the EBT attitudes scales, and both Beliefs About Session Structure subscales. All categorical variables for these analyses were dummy coded. Counseling served as the referential group for the professional discipline variables, while humanistic/psychodynamic clinicians served as the reference group for theoretical orientation. The assignment of dummy codes and results of the regression analyses are provided in Table 5.

Table 5.

Regression Analyses for Technique Selection.

Variable	Cognitive–behavioral	Play/experiential	Psychodynamic	Uncommon
Professional discipline
D1: Social Work	.04	−.11	.09	−.17*
D2: Psychology	−.04	−.16	−.12	−.13
Theoretical orientation
D1: Cognitive–behavioral	.15*	−.25**	−.17*	−.08
D2: Eclectic	.08	−.04	.01	−.01
Education level	−.03	−.09	−.07	−.07
Employment setting	−.05	−.09	.14*	.21**
EBPAS: Requirements	.02	.03	−.01	−.01
EBPAS: Appeal	.16*	.02	−.04	−.04
EBPAS: Openness	.28***	.07	.01	.15
EBPAS: Divergence	−.06	.01	.12	.15
BASS: Clinician-Directed	.28***	−.27***	−.07	−.09
BASS: Verbal Capacity	.16**	−.21**	−.22**	−.07
Model R ²	.43	.35	.24	.17
Model F(12, 206)	13.01***	9.28***	5.35***	3.53***

Note. EBPAS = Evidence-Based Practice Attitudes Scale; BASS = Beliefs About Session Structure Scale; CAC = children’s advocacy center. All values reported are standardized βs. Counseling and humanistic/psychodynamic clinicians were the referential groups for professional discipline and theoretical orientation, respectively. In addition, the following dummy codes were used: education level (0 = Master’s degree, 1 = Doctoral degree), employment setting (0 = CAC, 1 = Other Setting).

*p < .05. **p < .01. ***p < .001.

The first regression analysis examined variables related to selection of cognitive–behavioral techniques. The resulting equation was significant and accounted for a moderate amount of variance. Cognitive–behavioral technique selection was related to greater belief in clinician-directed/structured sessions and a greater openness to using research-based interventions. In addition, a greater belief in children’s ability to verbally discuss traumatic events remained positively related to cognitive–behavioral technique selection. In addition, a cognitive–behavioral theoretical orientation was related to greater selection of these techniques than a humanistic/psychodynamic orientation.

The second regression equation examining the likelihood of selecting play/experiential techniques was also significant and explained a modest amount of variance. Only three variables remained significant correlates of the selection of play/experiential techniques after controlling for other variables in the model. Higher Clinician-Directed and Verbal Capacity beliefs were related to less endorsement of play/experiential techniques. Not surprisingly, humanistic/psychodynamic clinicians continued to display a greater preference for these techniques than cognitive–behavioral clinicians.

As for the psychodynamic techniques, the overall regression equation was significant and accounted for modest variance. A greater skepticism in the ability of children to discuss trauma (lower scores on verbal capacity) was related to greater psychodynamic technique selection. This lack of belief in the verbal capacity of children may prompt clinicians to prefer the more interpretive techniques found on the psychodynamic scale. Interestingly, employment in a non-CAC community setting remained related to a greater likelihood of selecting psychodynamic techniques. In addition, humanistic/psychodynamic clinicians continued to show a greater preference for these techniques than cognitive–behavioral clinicians.

The regression model for uncommon techniques explained modest variance. Those trained in the counseling profession continued to display a greater likelihood of selecting uncommon techniques when compared to social workers. In addition, clinicians in non-CAC settings were more open to these techniques than CAC clinicians. No other variables were related to the likelihood of selecting uncommon treatment techniques.

Discussion

The current study sought to examine clinicians’ beliefs about the treatment process as well as how those beliefs impact the selection of treatment techniques with children who experienced maltreatment. Results indicated that, generally, the sampled clinicians held a slightly nondirective/unstructured belief of the treatment process and were unsure about whether children have the verbal capacity to describe traumatic experiences. In addition, these beliefs about clinical practice were weakly related to clinicians’ attitudes toward EBTs.

The most common treatment techniques selected were cognitive–behavioral in nature; however, different factors emerged as related to the selection of techniques. Analyses demonstrated that a greater likelihood of selecting cognitive–behavioral techniques was associated with a more directive approach to treatment and a greater belief in the verbal capacity of children to discuss trauma, as well as being more open to research-based interventions. The opposite picture was present, however, when examining play/experiential techniques, as clinicians with more nondirective/unstructured beliefs and less confidence in the verbal capacity of children were more inclined to select these techniques. Similarly, the selection of psychodynamic techniques was most notably associated with less confidence in the ability of children to describe their traumatic experiences. This belief may explain clinicians’ selection of techniques that emphasize clinician interpretation of nonverbal material from the child.

It is worth noting that cognitive–behavioral clinicians, although reporting greater selection of cognitive–behavioral techniques, a greater appreciation for principles of EBTs, and a greater belief in the capacity of children to discuss trauma, still reported a slight nondirective/unstructured orientation to treatment. This creates an interesting paradox as cognitive–behavioral techniques are generally considered as some of the most directive therapeutic methods; however, despite attitudes congruent with the use of these techniques, cognitive–behavioral clinicians did not appear decidedly directive/structured in their clinical approach. These findings create concerns about the validity of using clinician-reported theoretical orientation as a gauge of the type of treatment implemented in practice. More to the point, this finding raises questions about whether self-professed cognitive–behavioral clinicians, using cognitive–behavioral interventions, are delivering the techniques in the manner prescribed or whether endorsement of the use of these techniques is driven by other factors (e.g., pressure to use EBTs and the popularity of various cognitive–behavioral interventions in the maltreatment field).

Allen et al. (2012) found that attitudes toward EBTs did not predict the selection of or training to use interventions not typically considered evidence based. In instances where clinicians hold more nondirective/unstructured beliefs, or doubt the ability of children to discuss trauma, they may view other interventions not considered evidence based or trauma focused as more suited to the treatment needs of the child, regardless of their attitudes toward EBTs. The current study supported this contention by finding that more nondirective/unstructured beliefs were strongly related to the selection of play/experiential techniques and less confidence in the verbal capacity of children to discuss trauma were powerful predictors of both play/experiential and psychodynamic techniques. The use of these approaches is generally not considered evidence based or trauma focused but have enjoyed historical acceptance for use with children experiencing maltreatment.

The findings in this study may help explain various contradictory reports in the literature. Kolko, Cohen, Mannarino, Baumann, and Knuden (2009) reported that clinicians serving maltreated children tend to report positive attitudes toward the use of treatment manuals, but their analyses suggested only weak to moderate relationships between attitudes and practices. Also of note, Allen and Johnson (2012) found that the vast majority of clinicians in community practice serving maltreated children reported using TF-CBT, a trauma-focused EBT. However, only 66% of them reported frequently using all of the components, and the techniques most likely to be omitted were the ones that involved directly discussing and processing the traumatic experiences. Results such as these suggest that clinicians may hold generally positive attitudes toward EBTs and are willing to use research-based interventions in practice, yet other factors mitigate the implementation of EBTs with fidelity. The current findings suggest that more foundational clinical beliefs, such as level of clinician directiveness/structure and belief in the child’s ability to discuss trauma, may be influential. Clinicians may find it difficult to implement certain techniques or components of treatment protocols if they fundamentally conflict with their clinical understanding of the treatment process. Although they may value empirical findings and be open to the use of manuals, they may omit or find it difficult to implement the more trauma-focused or clinician-directed components.

Chorpita and Daleiden (2009) attempted to identify specific treatment techniques, or “practice elements,” that were common across EBTs. They conducted an analysis of 615 separate treatment protocols for children, which were tested in 322 randomized clinical trials. The items composing the cognitive–behavioral subscale of this new techniques measure closely reflect those individual techniques identified by Chorpita and Daleiden as common among EBTs for childhood anxiety, depression, posttraumatic stress, defiance, and other concerns. As such, the cognitive–behavioral subscale may serve as a useful proxy for self-reported use of EBT techniques.

These results imply that clinicians’ fundamental beliefs about the treatment process are strongly related to the selection of EBTs. Although this study was cross sectional, it is possible that instilling a more directive clinical approach in students during their training may prompt greater use of EBTs. Alternatively, some evidence suggests that practicing clinicians who receive training and supervision in the use of a trauma-focused EBT subsequently demonstrate a greater belief in directive/structured sessions and the verbal ability of children to discuss trauma (Allen & Armstrong, in press-b). The conclusion was that providing clinicians with experience in the effective use of these techniques caused a fundamental change in their clinical process beliefs. As such, effective avenues toward increasing the use of EBTs might be through either instilling beliefs that are conducive to the implementation of EBTs early in training or providing clinical experiences for practicing clinicians that challenge their clinical beliefs about directiveness/structure and the verbal ability of children to discuss trauma and abuse.

This study also provides some suggested directions for the field of implementation science, especially as related to the child maltreatment field. Notably, the emphasis placed on examining attitudes toward EBTs and their role in clinical practice may obscure the role of other beliefs and attitudes. Equally important, if not more so, may be clinicians’ fundamental beliefs about the treatment process. Examining these beliefs in future studies examining implementation or sustainability of EBTs may provide useful information regarding the reasons for program success or failure. In addition, examining ways of bringing clinicians’ beliefs about the treatment process more in line with the current empirical evidence may be beneficial for the dissemination and implementation of EBTs, including trauma-focused interventions for children experiencing maltreatment.

The current study is not without limitations. First, all data for this study were provided through clinician self-report. The accuracy of these reports in terms of actual clinical practice cannot be verified. Also, the potential for common method variance inherent in self-report measures completed at one point in time should be considered. Second, two of the primary scales utilized (i.e., the Beliefs About Session Structure and the Treatment Technique Scales) were developed for use in this study and have not been subjected to structural analysis outside of the current sample. Further exploratory and confirmatory analyses of these scales will be required for greater confidence in their usage across samples. Third, the sample consisted largely of seasoned clinicians with an average of 13.2 years of clinical experience. It is unclear whether the same results would be observed with a more novice group of clinicians. Finally, the estimated survey response rate was relatively low. Approximately half of the clinicians in the sample were from CACs, and specific EBT dissemination efforts have targeted clinicians and administrators working in CAC settings (Child Welfare Committee, National Child Traumatic Stress Network, & National Children’s Alliance, 2008). In addition, clinicians who responded to the survey may differ qualitatively from those who did not respond. Specifically, clinicians uninterested in EBTs or unwilling to assist in research efforts may have been more likely to decline participation. Taken together, these sources of sample bias may result in the presentation of a more favorable attitude toward EBTs and greater reporting of more directive and trauma-focused techniques and beliefs than actually exists in the broader clinical community.

A few comments are necessary regarding the Beliefs About Session Structure and Treatment Techniques Scales. Clinicians were instructed to provide their responses to the scales based on the hypothetical treatment of a child aged 12 years or younger. No lower limit on age was provided. Clinical trials demonstrate that children as young as 3 years are capable of participating in verbally mediated, trauma-focused treatment that resembles EBTs for older children (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011). As a result, the items on the scales appear valid for the 3–12 age range; however, the items of the scales should not be considered valid for children aged 2 years and younger. The scarcity of mental health resources for maltreated children under the age of 3 suggests that the omission of this lower age limit in the current study posed a minimal impact on the results; however, the degree of impact cannot be known. Future use of the scale should specify that the questions relate to the treatment of a child between the ages of 3 and 12. Furthermore, the development and testing of additional items for the Beliefs About Session Structure Scale should be considered to improve internal consistency. Validation of the Techniques Scale by correlating clinician report with observational data from clinical sessions would be beneficial.

Finally, research clearly implicates the larger social context and culture of one’s clinical setting as related to EBT utilization (Glisson, et al., 2008; Schoenwald, et al., 2008). For instance, more supportive administrative structures predict more favorable attitudes toward EBTs (Aarons & Sawitzky, 2006), and smaller caseloads and fewer time constraints increase the likelihood of EBT utilization (Jensen-Doss et al., 2009). At present, it is unclear how these organizational and practical factors might be related to clinicians’ beliefs regarding clinician-directedness and children’s verbal capacity to discuss trauma, or how these beliefs fit within the larger body of implementation science literature. Answering these questions may provide a clearer picture of the mechanisms and approaches that will yield the greatest benefit in changing clinicians’ beliefs and practices to align more with an evidence-based perspective and ultimately improve the standard of care for maltreated children.

Footnotes

Appendix A

Appendix B

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

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Aarons

G. A.

(2004). Mental health provider attitudes toward adoption of evidence-based practice: The evidence-based practice attitude scale (EBPAS). Mental Health Services Research, 6, 61–74.

Aarons

G. A.

Cafri

Lugo

Sawitzky

(2012). Expanding the domains of attitudes towards evidence-based practice: The evidence-based practice attitude scale-50. Administration and Policy in Mental Health and Mental Health Services Research, 39, 331–340.

Aarons

G. A.

Glisson

Hoagwood

Kelleher

Landsverk

Cafri

(2010). Psychometric properties and U.S. national norms of the evidence-based practice attitude scale (EBPAS). Psychological Assessment, 22, 356–365.

Aarons

G. A.

Sawitzky

A. C.

(2006). Organizational culture and climate and mental health provider attitudes toward evidence-based practice. Psychological Services, 3, 61–72.

Allen

Armstrong

N. E.

(in press-a). Burden of proof: The evidence clinicians require before implementing an intervention. Child and Adolescent Mental Health.

Allen

Armstrong

N. E.

(in press-b). Changing clinicians’ beliefs about treatment for maltreated children: The impact of intensive training in an evidence-based, trauma-focused treatment. Psychological Trauma: Theory, Research, Practice, and Policy.

Allen

Gharagozloo

Johnson

J. C.

(2012). Clinician knowledge and utilization of empirically-supported treatments for maltreated children. Child Maltreatment, 17, 11–21.

Allen

Johnson

J. C.

(2012). Utilization and implementation of trauma-focused cognitive-behavioral therapy for the treatment of maltreated children. Child Maltreatment, 17, 80–85.

Axline

(1947). Play therapy. Oxford, England: Houghton Mifflin.

10.

Borntrager

Chorpita

B. F.

Higa-McMillan

C. K.

Aleiden

E. L.

Starace

(2013). Usual care for trauma-exposed youth: Are clinician-reported therapy techniques evidence-based-based? Children and Youth Services Review, 35, 133–141.

11.

Cary

C. E.

McMillen

J. C.

(2012). The data behind the dissemination: A systematic review of trauma-focused cognitive-behavioral therapy for use with children and youth. Children and Youth Services Review, 34, 748–757.

12.

Child Welfare Committee, National Child Traumatic Stress Network, & National Children’s Alliance. (2008). CAC director’s guide to mental health services for abused children. Los Angeles, CA: National Center for Child Traumatic Stress.

13.

Chorpita

B. F.

Daleiden

E. L.

(2009). Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77, 566–579.

14.

Cohen

(1992). A power primer. Psychological Bulletin, 112, 155–159.

15.

Cohen

J. A.

Mannarino

A. P.

Deblinger

(2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press.

16.

Cohen

J. A.

Mannarino

A. P.

Iyengar

(2011). Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: A randomized controlled trial. Archives of Pediatrics and Adolescent Medicine, 165, 16–21.

17.

Courtois

C. A.

Gold

S. N.

(2009). The need for inclusion of psychological trauma in the professional curriculum: A call to action. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 3–23.

18.

Deblinger

Mannarino

A. P.

Cohen

J. A.

Steer

R. A.

(2006). A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1474–1484.

19.

Glisson

Schoenwald

S. K.

Kelleher

Landsverk

Hoagwood

K. E.

Mayberg

Green

(2008). Therapist turnover and new program sustainability in mental health clinics as a function of organizational culture, climate, and service structure. Administration and Policy in Mental Health and Mental Health Services Research, 35, 124–133.

20.

Jensen-Doss

Hawley

K. M.

Lopez

Osterberg

L. D.

(2009). Using evidence-based treatments: The experiences of youth providers working under a mandate. Professional Psychology: Research and Practice, 40, 417–424.

21.

Kazdin

A. E.

, (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146–159.

22.

Kolko

D. J.

Cohen

J. A.

Mannarino

A. P.

Baumann

B. L.

Knudsen

(2009). Community treatment of child sexual abuse: A survey of practitioners in the national child traumatic stress network. Administration and Policy in Mental Health and Mental Health Services Research, 36, 37–49.

23.

Lieberman

A. F.

Van Horn

(2005). Don’t hit my mommy! A manual for child-parent psychotherapy with young witnesses of family violence. Washington, DC: ZERO TO THREE PRESS.

24.

Lieberman

A. F.

Van Horn

(2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press.

25.

McNeil

C. B.

Hembree-Kigin

T. L.

(2010). Parent-child interaction therapy (2nd ed.). New York, NY: Springer.

26.

Miller

W. R.

Rollnick

(2012). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

27.

Nelson

T. D.

Steele

R. G.

(2007). Predictors of practitioner self-reported use of evidence-based practices: Practitioner training, clinical setting, and attitudes toward research. Administration and Policy in Mental Health and Mental Health Services Research, 34, 319–330.

28.

Olatunji

Deacon

Abramowitz

(2009). The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cognitive and Behavioral Practice, 16, 172–180.

29.

Pynoos

R. S.

Fairbank

J. A.

Steinberg

A. M.

Amaya-Jackson

Gerrity

Mount

M. L.

Maze

(2008). The national child traumatic stress network: Collaborating to improve the standard of care. Professional Psychology: Research and Practice, 39, 389–395.

30.

Scheeringa

M. S.

Weems

C. F.

Cohen

J. A.

Amaya-Jackson

Guthrie

(2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52, 853–860.

31.

Schoenwald

S. K.

Chapman

J. E.

Kelleher

Hoagwood

K. E.

Landsverk

Stevens

J.,

… Rolls-Reutz

(2008). A survey of the infrastructure for children’s mental health services: Implications for the implementation of empirically-supported treatments (ESTs). Administration and Policy in Mental Health and Mental Health Services Research, 35, 84–97.

32.

Sigel

B. A.

Silovsky

J. F.

(2011). Psychology graduate school training on interventions for child maltreatment. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 229–234.

33.

Stewart

R. E.

Chambless

D. L.

Baron

(2012). Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments. Journal of Clinical Psychology, 68, 8–23.

34.

Zeldow

P. B.

(2009). In defense of clinical judgment, credentialed clinicians, and reflective practice. Psychotherapy: Theory, Research, Practice, & Training, 46, 1–10.