A core competencies approach to family-based intervention for child and adolescent mental health

In recent decades, there has been a shift from traditional training models in health education to a core competencies approach. Traditionally, clinical training in many fields of health focused predominantly on the content of clinical theory and practice, and schedules of clinical placements (e.g., number of direct client contact hours; supervision hours; days on placement). In contrast, competency-based training focuses on the competencies that enable practitioners to effectively implement evidence-based practice, emphasising teaching and assessment methods that ensure trainees develop these competencies.

The competency-based movement has become particularly influential in clinical psychology. Competencies are defined very broadly, and include specific skills, behaviours, attitudes, knowledge, and personal factors that influence therapists' ability to implement evidence-based practice. Competency-based education, training, and assessment programmes have gained popularity in recent years due to the recognition that poor implementation of evidence-based practice may be at least partly due to ineffective training approaches. Many countries – including the UK, USA, Canada and Australia – are now taking a competency-based approach to the training of mental health practitioners.

To facilitate the regulation of teaching curriculums, Anthony Roth and Stephen Pilling (2008) proposed a model of therapist competencies for delivering cognitive behaviour therapy (CBT) to adults with depression and anxiety. This model has been highly influential, and its development occurred as part of a large-scale initiative to increase the quality and dissemination of evidence-based treatment in England, known as Improving Access to Psychological Therapies (IAPT). Since it started in 2008, IAPT has grown to treat over 560,000 people each year. Outcomes are generally consistent with the evidence base, with roughly 50 per cent of adults recovering and another two-thirds showing reliable improvement. IAPT reresented a significant advancement for mental health practitioners in England, as prior to this, adults suffering from anxiety and depression were offered medication as the sole treatment option.The Children and Young People's Improving Access to Psychological Therapies (CYP-IAPT) programme, launched in the UK in 2011, has demonstrated that the benefits of such a model can extend to child mental health. CYP-IAPT involves the use of manualised treatment protocols supported by RCT evidence, and therapists must demonstrate that they possess the set of competencies required for the effective implementation of these evidence-based treatments. Similar to the findings in adult mental health services, IAPT in CAMHS also showed positive outcomes; including decreased waiting times, and greater use of outcome data by clinicians to inform therapy and engage in shared decision-making with children and parents. Children reported feeling empowered by their involvement in service delivery, and that ongoing monitoring helped them to maintain focus during treatment. These positive outcomes highlight the importance of a core competencies-based training curriculum to the successful implementation of evidence-based practice with children and their families in 'real-world' clinical settings.

During this time, progress was also being made in identifying the core competencies underlying the evidence-based treatment of various problems in child mental health. Notably, Sburlati, Rapee and colleagues at the Centre for Emotional Health, Macquarie University, Australia, developed a competency-based training model for CBT for anxiety and depression in children and adolescents (Sburlati et al., 2011). This model represented a critical step toward establishing a competencies-based curriculum for child mental health that incorporated both the child and the family environment. While CBT for anxiety and depression in children is typically a downward extension of adult treatment, this model identified additional competencies of unique importance for children and young people, including:

• Knowledge of typical developmental processes across childhood and adolescence
• Understanding family factors implicated in the maintenance of these disorders
• Knowledge of the legal and ethical requirements relating to the provision of therapy to children and families
• Ability to build positive therapeutic relationships with parents and the collaborative involvement of parents in treatment
• Ability to implement CBT-specific techniques that aim to change the family environment (e.g., family communication).

A competencies approach to family-based intervention

In 2017, we discussed the need for a practitioner handbook on evidence-based family intervention for child and adolescent mental health. Family-based models of child and adolescent disorders have evolved considerably in recent years, and key advances have been made in the translation of these models into clinical strategies. Despite this, published literature regarding the treatment of mental disorders in childhood and adolescence has continued to focus primarily on the child in isolation from the family, or on outdated models of family therapy. We wanted to promote the dissemination of family-based intervention for a range of disorders that actively involve parents or caregivers in key roles, including those that can be delivered to be children and parents through separate or parallel processes. There was a real gap in this area, and we felt that a high-quality resource on evidence-based family-based intervention for trainee practitioners was sorely needed.

We excitedly started exchanging ideas. Initial discussions stemmed from our reflections on the following questions: How could the text support people to develop into effective reflective scientist practitioners in psychology? What did we really want (and need!) when we were trainee psychologists?

We decided that the book would differ from other texts in that the major focus would be on i) competencies that are core to the delivery of evidence-based interventions, and ii) the adaptation of interventions for children and families who that present with distinct needs in terms of comorbidity and family adversity.

We also wanted to highlight intervention programmes that are evidence-based, with support for their effectiveness supported by findings from randomised controlled trials (RCTs). An important role of any practitioner text is to further promote the dissemination of evidence-based treatment. Yet the term 'evidence-based' can be used quite loosely, with this term applied to treatments who have not yet progressed their evaluation beyond case studies or nonrandomised trials. This didn't mean that we wished to overlook the clinical expertise of practitioners who are 'on the ground'. Often the complexity of issues faced by service users necessitates to adaptation of treatment to ensure treatment success. For these reasons, when we contacted contributors, we requested that they were transparent about which strategies were evidence-based, and which were derived from their own clinical experience in implementing their family-based intervention programme.

It was important to us for the book have a practical focus. We wanted to provide guidance on the adaptation of standardised intervention components for complex cases that present with distinct needs in terms of comorbidity and risk markers, and in the context of parent mental health problems and exposure to child and family adversity. This is consistent with a personalised approach to family-based intervention which ensure that treatment is a good fit for children and families based on their child's unique characteristics (e.g., child temperament, comorbidity), family characteristics (e.g., foster carers, parent mental health) and social circumstances (e.g., child maltreatment). One way of achieving this was to request that contributors all included case study examples to illustrate how to implement their treatment programme effectively, highlighting common barriers to treatment and how these could be managed.

We also wanted to be inclusive of a variety of evidence-based therapeutic approaches. Previous texts on family intervention tend to feature only therapies derived from one theoretical framework, such as CBT or family systems. We decided to use the term 'family-based' to be inclusive of all interventions in which caregivers played an active role in promoting child and adolescent mental health. Many interventions, particularly those designed for toddlers and young children may be solely delivered to parents, while for adolescents, treatment may be chiefly directed towards the young person, with parents attending fewer sessions.

The handbook also highlights advances and innovations in family-based intervention, such as therapies based on an emotion coaching model, such as Sophie Havighurst's Tuning Into Kids (TIK) programme (see chapter 20). Increasingly, the field of family intervention is recognising the need for hybrid approaches integrating theoretical perspectives to improve outcomes for children and families. This is often where the most treatment innovation stems from and is likely to help when working with children and families with complex needs. For example, in chapter 10, David Hawes and Mark Dadds explain how to integrate concepts and strategies derived from attachment and family systems theories with social-learning theory-based parent training when working with families of children with conduct problems. In chapter 21, Lynn Fainsilber Katz and Kyrill Gurtovenko describe their treatment for families of children with behaviour problems who have experienced intimate partner violence which involves integrating social learning theory-based parent training with emotion coaching.

A major aim was to support practitioners working with children and families in real-world clinical settings, which can differ markedly from the settings in which research is often conducted. Practitioners working with children and families know that seeing a child with only one type of mental health problem tends to be more an exception than the rule. For example, anxious children typically have more than one form of anxiety (e.g., social anxiety as well as the chronic, difficult to control worry seen in generalised anxiety disorder), and anxious adolescents may also have comorbid depression. Although most mental health interventions for children and adolescents have emerged from a focus on a specific disorder, children often present with comorbid problems, and this can impact on the successful delivery of family intervention. Similarly, parents of children with mental health problems often also have mental health problems, most commonly depression and anxiety. Practitioner competencies for engaging parents with mental health problems of their own in interventions focused on their children are vital, and are addressed throughout the volume accordingly.

We became excited through sharing our ideas and slowly the vision for the handbook fell into place. In line with a competency-based approach, we asked authors describing intervention programmes: (1) What do you consider to be the most important therapist competencies for achieving successful outcomes in the treatment presented in your chapter? (2) Why are those competencies important when working with more severe/complex cases? (3) What aspects of those competencies are commonly misunderstood by new clinicians when beginning to deliver such therapy? (4) What recommendations do you have for therapists wanting to develop those competencies?  Contributors addressed the competency domains identified in the Sburlati, Schniering, Lyneham and Rapee (2011) model, which groups competencies into three domains:

(1) Generic therapeutic competencies related to all forms of therapy (e.g., knowledge of development and psychopathology, including common comorbidity; clinical engagement of children, adolescents, parents, and families; Assessment of child/adolescent problems; Culturally responsive practices with diverse populations);

(2) CBT and other theory-based competencies involved in child and adolescent mental health (e.g., Understanding of maintaining factors and change mechanisms, including those concerning specific disorders or forms of comorbidity; Devising, implementing, and revising case formulations and treatment plans; Collaborative treatment processes; Using CBT or other theory-based strategies to conceptualise and manage interparental conflict/divorce/separation when working with families);

(3) Specific evidence-based techniques for the treatment of child and adolescent psychopathology (e.g., Specific types of skills training to target thoughts and behaviours, such as 'cognitive restructuring'; specific types of strategies for modifying family environment such as a 'behaviour correction routine' for parents).

Developing a unified model

Hearing about the exciting work in family-based intervention around the world inspired us to develop a new model of core competencies for the family-based treatment of child and adolescent psychopathology. Existing models were designed for adult mental disorders or were predominantly focused on CBT strategies that were child-directed. Our new, unified model of core competencies extends the work of previous models by:

1. Including any evidence-based treatment with parental or family involvement, from treatments that include the whole family to those that may be partly or solely directed towards parents;
2. Covering a broad range of child and adolescent mental health problems in addition to anxiety and depression, such as child conduct problems, ADHD, eating disorders, sleep disorders and autism.
3. Including evidence-based approaches in addition to CBT, such as attachment therapy and family systems theory. While CBT is the first line treatment for many types of mental health problems in childhood or adolescence, this isn't always the case - for example for eating disorders, the first line recommended treatment is Maudsley family therapy, which is based on a family systems model.
4. Providing a good fit with the complexity of child mental health problems in clinical practice. The models aims to equip practitioners to work with children and families where comorbid mental disorders are present, current or past adversity, and when one or more caregivers have a mental health problem.

This unified model was directly informed by the work of these contributors, and the overarching questions they addressed as this volume emerged. We first asked contributors to identify competencies needed to effectively implement their evidence-based treatment programme. The first editor reviewed each chapter and extracted a full list of competencies. These competencies were then refined and modified by the co-editors. We also drew on policy frameworks (Australian CAMHS), and competency frameworks published by university doctorate in clinical psychology training programmes (see: www.ucl.ac.uk/CORE). Identified competencies mapped onto three tiers (that can be seen in Figure 1 depicting the model):

Generic Therapeutic Competencies relates to foundational competencies needed in all forms of therapy, such as professional, ethical and legal codes of conduct, and possessing an openness towards psychotherapy research and an orientations toward evidence-based treatment.

The next level describes Competencies in Treatment Planning and Delivery. These include includes knowledge and abilities that establish the structure and context for delivering specific models of intervention, and needed to plan, implement and flexibly adapt evidence-based treatment components given the unique considerations and needs associated with specific clinical settings and specific families.

The third domain, Competencies for Targeting Specific Ecological Domains, relates to the therapists' ability to deliver the content of therapeutic components (e.g., psychoeducation; skills training in parenting strategies) in a specific treatment plan. The conceptualisation of this domain is informed by an ecological perspective on the various levels at which treatment targets within a family-based intervention may be situated (e.g., individual child/adolescent; dyadic relationships; family-level, school).

The new unified model can help to guide curricula planning and assessment by focussing training on the core competencies needed to effectively implement evidence-based strategies, to gauge where practitioners are at currently in terms of their development, and where and how they need to improve to ensure positive outcomes for children and families. Providing one model that works for all therapeutic orientations will make assessing and teaching trainee practitioners simpler and more useful for training programmes.

We always viewed our model as the start of a conversation, rather than an end point. We are currently planning a Delphi study to further develop and refine the model. We would like to hear from practitioners, particularly those working from theoretical frameworks outside of CBT, relevant stakeholders (practitioners working in CAMHS, teachers) and service users or experts by experience to provide feedback. In particular, we invite contributions from those in non-English-speaking countries. We would also like to extend the model to include mental disorders that tend to have their onset in adolescence, such as psychosis and substance use. The views of all these different parties will be gathered and then synthesized to further develop and refine the model. Please email me at [email protected] to provide any feedback.

Next steps for training in family-based intervention

Since the handbook was finalised, many world-changing events have occurred. Black Lives Matter has led to a long overdue emphasis on acknowledging and addressing barriers to service access, and the role of practitioners in advocating for equality and inclusivity of care. More recently, war in Europe and the Middle East has highlighted the plight of families and children living in warzones, and refugee children and families. The climate crisis  has led to increased natural disasters, financial stress and climate refugees. In parallel with these world events, there has been a much-needed shift towards trauma-informed care, and consequently, a shift towards trauma-informed pedagogy.

The world experienced a pandemic, which led to a new awareness of the impact of loneliness and social isolation on families, and the need for effective phone and internet-based delivery of treatment. It increased awareness of children at greater risk of mental health difficulties due to lockdowns and home-schooling, such as families who are clinically vulnerable and shielding, those who experience violence and maltreatment at home, children with neurodevelopmental disorders; and socially disadvantaged families, who often live in dense urban spaces with little access to green space.

Where to next? Current trends indicate that ensuring that intervention is inclusive of families in all their forms is vital. There is now a long-overdue impetus on ensuring that families with diverse experiences and backgrounds can access evidence-based treatment, and that these treatments are engaging, effective and sensitive to their needs. Engaging young people and caregivers with lived experience is helping to improve access to psychological intervention, leading the way to more holistic care. Treatment is aimed at increasing child and family well-being and quality of life rather than purely reducing symptoms and impairment. There is also increased recognition of the need to address systemic factors, including structural racism and discrimination, and to acknowledge the strengths of individual children and their families.

• Jennifer Allen (Department of Psychology, University of Bath), David Hawes (Department of Psychology, University of Sydney) and Cecilia Essau (Department of Psychology, University of Roehampton)

Key sources

Allen, J.L., Hawes, D.J., & Essau, C.A. (2021). Family-based Intervention for Child and Adolescent Mental Health: A Core Competencies Approach. Cambridge: Cambridge University Press.

Allen, J.L., Hawes, D.J., & Essau, C.A. (2021). A Core Competency Perspective on Family Intervention to Child and Adolescent Mental Health. In J.L. Allen, D.J. Hawes & C.A. Essau (Editors), Family-based Intervention for Child and Adolescent Mental Health: A Core Competencies Approach. Cambridge: Cambridge University Press.

Roth, A.D., & Pilling, S. (2008). A competence framework for the supervision of psychological therapies. Retrieved August 2008; 18:2011.

Sburlati, E. S., Schniering, C. A., Lyneham, H. J., & Rapee, R. M. (2011). A model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders. Clinical Child and Family Psychology Review, 14(1), 89-109.