The document presents a randomized trial comparing trauma-focused cognitive behavioral therapy (TF-CBT) with and without additional engagement strategies for foster parents. Findings indicate that engagement strategies significantly improved participation rates in active treatment sessions, with foster parents in the engagement group attending more sessions and being less likely to drop out. However, clinical outcomes showed no significant differences between the two groups, suggesting that while engagement supports attendance, it does not necessarily lead to improved results in therapy.

1. A RANDOMIZED TRIAL COMPARING
TF-CBTAND TF-CBT PLUS
ENGAGEMENT STRATEGIES FOR
FOSTER PARENTS
Lucy Berliner, Shannon Dorsey, Michael Pullmann
University of Washington
BAPSCAN
Edinburgh, Scotland
April 14, 2015

2. Study Background
• Youth in foster care have high rates of trauma exposure and trauma
impact
• Entering foster care can increase access to psychosocial services
• TF-CBT is an evidence-based treatment for children with trauma-
specific distress
• Engagement in tx is challenging even when effective treatment is
available

3. Study Rationale and Hypothesis
• Engagement challenges for active therapies may be even
greater for foster parents
• Not traditionally an expectation
• Mary McKay’s evidence-based engagement steps work to
increase attendance
• Elicit client concerns, identify perceptual barriers to mental health
tx, actively problem solve concrete barriers, convey hope for
positive outcome.
Hypothesis: Addition of engagement strategies will
increase foster parent involvement in an active therapy

4. Procedure
• Permission, consent/assent obtained from all parties
(state, bio parent, foster parents, therapists, youth)
• Randomized to engagement/standard delivery (pre-tx
phone call; first in-person session)
• All children received TF-CBT
• Fidelity to TF-CBT, engagement checked by audio
recording

5. Table 1
Study sample: demographics and baseline characteristics
Youth Engagement
n = 25
Standard
n = 22
Age, M (SD) 9.52 (2.5) 9.64 (3.2)
Female, n (%) 15 (60%) 11 (50%)
Multiracial, n (%) 18 (72%) 7 (31.8%)
Caucasian, n (%) 3 (12%) 8 (36.4%)
African American, n (%) 3 (12%) 6 (27.3%)
Native American, n (%) 1 (4%) 0 (0%)
Asian, n (%) 0 (0%) 1 (4.5%)
Traditional foster care, n (%) 18 (72%) 11 (50%)
Kinship care, n (%) 6 (24%) 10 (45.5%)
Suitable adult/fictive kin, n (%) 1 (4%) 1 (4.5%)
Baseline caregiver age, M (SD) 45.3 (9.9) 47.5 (12.4)
Female, n (%) 22 (88%) 19 (86.4%)
Multiracial, n (%) 5 (20%) 1 (4.5%)
Caucasian, n (%) 16 (64%) 13 (59.1%)
African American, n (%) 3 (12%) 8 (36.4%)
Hispanic/Latino/a, n (%) 1 (4%) 0 (0%)

6. Table 1 (continued)
Incidence of trauma type
Foster parent endorsed…
Engagement
n = 25
Standard
n = 22
Cumulative number of trauma exposure
experienced, M (SD)
2.6 (.9) 3.2 (1.6)
Accident/natural disaster 0 (0%) 4 (18.2%)
Physical abuse 13 (52%) 14 (63.6%)
Witnessing domestic violence 22 (88%) 17 (77.3%)
Witnessing or experiencing community
violence
5 (20%) 7 (31.8%)
Sexual abuse 2 (8%) 8 (36.4%)
Violent death/injury 10 (40%) 6 (27.3%)
Painful/scary medical treatment 6 (24%) 1 (4.5%)
Other 8 (32%) 13 (59.1%)

7. Table 2
Treatment engagement and retention outcomes.
Treatment condition
Engagement (n = 25)
% (n)
Standard (n = 22)
% (n)
Showed to first scheduled intake 80.0 (20) 77.3 (17)
Attended one or more sessions 96.0 (24) 95.5 (21)
Attended four or more sessions 96.0 (24)* 72.7 (16)*
Treatment completed, or attended 11 or more sessions1 80 (20) 54.5 (12)
Treatment cancelations between intake and first month 29.2 (7) 52.4 (11)
Treatment status, end of study
Completed 80.0 (20) 40.9 (9)
Drop out 0 (0) 27.3 (6)
Placement disruption related 12.0 (3) 4.5 (1)
Declined to participate in treatment 4.0 (1) 4.5 (1)
Still in treatment 4.0 (1) 9.1 (2)
Other treatment recommended 0 (0) 13.6 (3)
Mean (SD) Mean (SD)
Total number of sessions attended1,2 15.0 (6.0) 12.3 (8.0)
1 Excludes participants still active in TF-CBT at the end of the study (n = 3).
2 Excludes participants who did not attend at least one session (n = 4).

8. 0%
10%
20%
30%
40%
<=3 4-10 11-15 16-20 21-25 26-30
Number of sessions attended
Session Attendance by Study Condition
Engagement
Standard

10. 0
20
40
60
80
100
Baseline End of treatment 3-month post treatment
Meanscore
Exploratory Analysis: Clinical outcomes for the combined sample1
PTSD (parent)
PTSD (child)
Externalizing Behav.
Depression
Child Strengths
Analysis: Two-level HLMs ran for all foster parents (n=37) and children (n=29) with at least one follow-up,
with time nested by client.
Slope p values: PTSD (parent), p = <0.001; PTSD (child), p = <0.001; CBLC (externalizing), p = 0.020;
CDI Total, p = 0.010; BERS, p = <0.001.
1Includes participants with a valid score at baseline and at least one follow-up point

11. Conclusions
• Engagement strategies were associated with increased
participation in active tx (4+ sessions).
• No differences in attendance at first session/no shows.
• May be because foster children are often required to attend to tx?
• Engagement condition less likely to drop out prematurely.
• No differences in outcomes between, but 4+ sessions
associated with improvement.
• Small sample size, reduced statistical power to detect difference
• Recent study shows that some children can benefit from relatively
few sessions of TF-CBT

12. Published Papers
• Dorsey, S., Pullmann, M., Berliner, L., Koschmann, E. F.,
McKay, M., & Deblinger, E. (2014). Engaging foster
parents in treatment: A randomized trial of supplementing
Trauma-focused Cognitive Behavioral Therapy with
evidence-based engagement strategies. Child Abuse and
Neglect. Advance online publication. PMCID:
PMC4160402. doi:10.1016/j.chiabu.2014.03.020
•
• Dorsey, S., Conover, K., & Cox, J. R. (2014). Improving
foster parent engagement: Using qualitative methods to
guide tailoring of evidence-based engagement strategies.
Journal of Clinical Child and Adolescent Psychology.
Advance online publication. PMCID: PMC4160431.
doi:10.1080/15374416.2013.876643