Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings

Most efforts to assess treatment integrity-the degree to which a treatment is delivered as intended-have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.