Table 1 Adaptations to family-based treatment (FBT) delivered in home-based settings
Adaptation | What is modified? | When, who involved in the modification, and preservation of core components? | Goal | Reasons |
|---|---|---|---|---|
Delivery of intervention in the home-based (or community-based) setting, rather than the office | a. Contextual modification at the organizational level - Setting (intervention delivered in a different setting–home-based versus office-based care) - Personnel (intervention delivered by clinicians who exclusively deliver intensive home-based care services) b. Content modification at the organizational level - Condensing and intensifying dose (30–96 h over 10–16 weeks, rather than 16–20 h over 6–12 months) | Proactive adaptation made in the planning/pre-implementation phase in collaboration with researchers and program manager(s) a. Contextual modification: Preserves the core elements and functions (i.e., FBT clinician can still work to empower the family within the home) b. Content modification: Does not change core elements and functions, but rather the way in which core elements (e.g., caregiver empowerment) are delivered | a. Contextual modification: - Increase reach/engagement - Increase retention - Improve feasibility - Improve fit with recipients, including cultural appropriateness - Increase satisfaction b. Content modification: - Improve clinical outcome | a. Contextual modification: - Recipient: mental health stigma impacting willingness to present for office-based care - Recipient: access to resources (including time, transportation) b. Content modification: - Sociopolitical: existing regulations requiring 3–6 h of treatment per week for home-based services reimbursement |
Additional opportunities for family meal coaching | Content modification at the organizational level (in response to intensifying dose for home-based care) - Adding elements (additional meals and greater opportunities for meal coaching with more diverse goals than the "one more bite" intervention) - Tailoring/refining the intervention (therapist may partake in meal, if culturally appropriate) | Proactive adaptation made in the planning/ pre-implementation phase in collaboration with researchers and program manager(s) Preserves the core elements and functions (i.e., FBT clinician can still work to empower the family within the home) | - Increase engagement - Improve fit with recipients, including cultural appropriateness - Increase satisfaction - Improve clinical outcomes | - Sociopolitical: existing regulations requiring 3–6 h of treatment per week for home-based services reimbursement - Provider: prior experience providing support to families in relevant daily activities as part of treatment - Recipient: caregivers often request more meal support; when families are "stuck" in FBT, caregivers often cite significant struggles in supporting their child at meals, and report that having a meal in the office setting does not approximate their experience in the home setting; may feel offended if therapist does not "join" them in eating |
Additional services to support family in grocery shopping and meal preparation | Content modification at the organizational level (in response to intensifying dose for home-based care) - Adding elements (support prior to meals) | Proactive adaptation made in the planning/ pre-implementation phase in collaboration with researchers and program manager(s) Preserves the core elements and functions (i.e., FBT clinician can still work to empower the family by asking how they would like to proceed at every step, reflecting on what they are doing, and reinforcing their efforts when effective) | - Increase engagement - Increase retention - Improve fit with recipients, including cultural and socioeconomic appropriateness - Improve clinical outcomes - Increase satisfaction | - Sociopolitical: existing regulations requiring 3–6 h per week of treatment for home-based services reimbursement - Provider: prior experience providing support to families in relevant daily activities as part of treatment - Recipient: caregivers may benefit from additional education about high density food options and preparations that fit within their budget |
Direct case coordination with school and other treatment providers | Content modification at the organizational level (in response to typical role of home-based provider) - Adding elements (therapist attends medical appointments, directly communicates with school to facilitate staff support of student) | Proactive adaptation made in the planning/pre-implementation phase in collaboration with researchers and program manager(s) Preserves the core elements and functions (i.e., FBT clinician can provide additional direct coordination with other treatment providers and school staff without undermining caregiver empowerment) | - Improve fit with recipients, taking into account family’s capacity to effectively advocate for their child in the context of potential language barriers and racial and ethnic or socioeconomic discrimination - Improve clinical outcomes through improved coordination and alignment among the treatment team, given the frequency of misaligned messaging to families that would complicate treatment - Increase satisfaction | - Organizational setting: service structure is one that supports high levels of coordination with other systems to provide intensive support to family - Sociopolitical: existing regulations requiring 3–6 h per week of treatment for home-based services reimbursement - Provider: prior experience providing intensive care coordination for their cases - Recipient: caregivers may not feel empowered to advocate for their child in the absence of prior experience doing so, and/or in systems that may not have been historically responsive to their concerns |
Incorporation of individual sessions with the adolescent focused on distress tolerance and coping skills | Content modification at the organizational level (in response to intensifying dose for home-based care) - Adding elements (individual sessions with adolescent, evidence-based skill building) | Proactive adaptation made in the planning/pre-implementation phase in collaboration with researchers and program manager(s) Preserves the core elements and functions (i.e., FBT clinician can still work to empower the family within the home) | - Improve acceptability/fit with recipients - Align intervention with cultural values/norms (i.e., families who may highly value adolescent independence) - Improve clinical outcomes | - Sociopolitical: existing regulations requiring 3–6 h per week of treatment for home-based services reimbursement - Provider: prefer to deliver interventions in which there is a significant individual therapy component - Recipient: adolescents and their caregivers often request more skills for the adolescent in the context of FBT |