Date of Graduation


Document Type


Degree Name

Doctor of Philosophy in Psychology (PhD)

Degree Level



Psychological Science


Timothy Cavell

Committee Member

Lauren Quetsch

Second Committee Member

Ellen Leen-Feldner


EPIS framework, evidence-based treatment, foster care, implementation, trauma


Youth in foster care experience trauma exposure and subsequent trauma-related disorders at much higher rates than their peers, with prevalence rates comparable with veterans of war. Although youth in foster care appear to receive services at higher rates than their peers, little is known about what outpatient care consists of, particularly for trauma-related disorders. Furthermore, although several evidence-based treatments exist for the treatment of child and adolescent trauma, little is known about how appropriate and effective existing treatment approaches are for youth in foster care. The current study used a mixed methods approach to examine a) the range of evidence-based approaches used by clinicians treating youth in foster care who have trauma symptoms, b) barriers and facilitators to treating this population, c) clinician attitudes toward evidence-based treatments (EBTs), and d) adaptations made to existing trauma treatments. Barriers and facilitators were assessed based on concepts outlined in the Exploration. Preparation, Implementation, and Sustainment (EPIS) framework (Aarons et al., 2011). These topics were assessed by a brief quantitative survey and a semi-structured qualitative interview. Participants (N = 148) were mental health clinicians with master’s (n = 126) and doctoral degrees (n = 22), primarily in social work (n = 106). A majority (91%) of providers reported using at least one evidence-based treatment (EBT) when working with youth in foster. Providers also reported using a number of treatment models with limited empirical support for the treatment of child trauma, such as client-centered play therapy (n = 68), art therapy (n = 68), and individual mind-body skills (n = 86). Quantitatively, providers reported encountering barriers (n = 127) more than facilitators (n = 50) when working with youth in foster care. Working with youth in foster care was widely described as more challenging than treating their typical caseload (n = 111) or other clients with trauma symptoms (n = 109). Participants reported most barriers to treating youth in foster care were related to outer contextual factors (i.e., external variables defined in the EPIS framework), such as working with caseworkers (n = 91), working with court systems (n = 77), and working with biological caregivers (n = 91). Conversely, providers described inner contextual variables (i.e., internal variables defined in the EPIS framework) as facilitators, such as agency policies and support (n = 68) and clinician practices (n = 89). Total scores on a measure of evidence-based practice attitudes (EBPAS) were higher than community samples (M = 2.86, SD = 0.53). Qualitatively, providers reported making modifications to existing trauma treatments, such as eliminating narration and increasing an emphasis on feeling identification, which may lead to drops in efficacy. Providers described existing treatment models as appropriate and effective with youth in foster care but indicated that external challenges prevent model use. Implications for policymakers, stakeholders, and implementation developers include capitalizing on widely disseminated interventions, considering the fit between provider theoretical orientation and model theory, and adapting existing interventions to match the needs of youth in foster care.