Provider-Level Manual Adaptation: Patterns, Predictors, and Impact on Child Outcomes

Manualized, evidence-based treatments (EBTs) for children are being increasingly incorporated in community mental health clinics. Yet, providers hold concerns about the appropriateness of manuals for community populations, as suggested by the research of Jensen-Doss, Hawley, Lopez and Osterberg. Such concerns could lead them to adapt EBTs in the field, potentially diminishing or increasing their effectiveness. Therefore, it is striking how little is known about provider-level manual adaptation in community settings. The present study investigated the extent to which therapists mandated to use a manualized EBT adapt the treatment in the field, including patterns, predictors and outcomes of adaptation. A typology of provider-level manual adaptation was created to describe sessions double-dipped (i.e., repeated), skipped, or flipped (i.e., delivered in reverse order). Patterns of manual adaptation used by a sample of 38 community therapists treating 288 depressed youths with Lewinsohn and colleagues? Adolescent Coping with Depression course (CWD-A) were described. Hierarchical Linear Modeling was used to identify which client and therapist characteristics predict manual adaptation, and whether adaptation is associated with greater improvement or worsening in youths? therapy outcomes. Adaptation was widespread and largely unsystematic, with no significant client predictors of repeats or flips. Sessions were skipped more often for youths belonging to families with higher income and youths with greater pre-treatment symptom severity, but less often for Hispanic and Asian youths relative to Caucasians. A significant portion of variability in adaptation was attributable to therapists, who showed habits in manual adaptation: therapists with more years of experience working at the clinics double-dipped sessions more often, and Hispanic therapists flipped sessions much less often than Caucasian therapists did. Finally, adaptation was significantly related with outcomes, such that doubledips were associated with worsened symptom severity, skips were associated with improved symptom severity, and flips were associated with worsened functioning. Given that these data suggest manualized EBTs are likely to undergo vast adaptation in community settings, and that such adaptation is related to client outcomes, further research is necessary to better inform practitioners about when each type of manual adaptation may be appropriate. Practical implications for implementation efforts are discussed