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A Common Elements Approach to Children's Services

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1 A Common Elements Approach to Children's Services
Presented to the The Use of Evidence in Child Welfare Practice and Policy An International Perspective on Future Directions Haruv Institute, Jerusalem, Israel May 26, 2010 Richard P. Barth ATLANTIC COAST CHILD WELFARE IMPLEMENTATION CENTER School of Social Work University of Maryland Baltimore, MD 21201 Cycles—from the practical and specific to the general and conceptual Nearly 30 years ago I became very intrigued with evidence-based direct practice with children and families—the beginning of that movement. Most recently: NSCAW—service delivery at the national level A study about every aspect of CW in general For me, it’s time to cycle back and get specific; CAIRN has offered that. This training opportunity, too. Analyzing outcomes -SDM -AB 636

2 Summary Evidence based practices need to be based, primarily, on practice principles and common practice elements, not on manuals Increasing the uptake of evidence based methods will best be achieved by increasing knowledge of common practice elements and common factors Adapting evidence based practices to international contexts will require emphasis on common factors

3 The Alphabet of EBP What is needed, it seems to me, is some course of study where an intelligent young person can ... be taught the alphabet of charitable science. Anna Dawes (1883) From a paper given at the International Congress of Charities and Correction at the Chicago World's Fair. Source: Lehninger, L. (2000). Creating a new profession: The beginnings of social work education in the United states. Washington, DC: Council on Social Work Education.

4 The Language of Evidence Based Practices
Evidence Based Programs Multi-dimensional Evidence Supported Interventions Common (Practice) Elements Common Factors (CD OI) Client directed Outcome informed Coherent treatment strategy Practice Principles Practice (Policy) Framework

5 EBP and ESIs and Practice Guidelines
Evidence Based Practice Procedures and processes that result in the integration of the best research evidence with clinical expertise and client values Evidence Supported Interventions Interventions that have the support of the “best research evidence” showing their efficacy or effectiveness Practice Guidelines or Principles A set of strategies, techniques, and treatment approaches that support or lead to a specific standard of care that guides systems, care, and professions in their relationships to consumers

6 Building on Evidence Supported Interventions for Children and Families
Special Competence (Scores of These) Needed to increase the acceptability of services and, possibly, to improve interventions Evidence Supported Programs (A Few of These) Multi-systemic Therapy (MST); “Wrap Around” Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A) Evidence Supported Manualized Interventions (Scores or Hundreds) e.g., Cohen and Mannarino’s Trauma Focused-CBT Common (Practice) Elements Approach (28 Practice Elements) Chorpita and colleagues Common Factors Approach (3 Common Factors) Duncan, Lambert and Sparks (CDOI) Practice Principles Parent Training Dimensions (UK work or Hurlburt & Barth) Practice (Policy) Framework Commitment to “Place Matters” or “Family Focused Services” or “Safety, Permanency & Well-Being”

7 “Practice” (Policy) Framework
Specific Knowledge of Problem & Solutions Evidence Supported Programs (Manu alized Interv ention s) Common (Practice) Elements Not Drawn to Scale Regarding Importance ARE WE FOCUING ON THE RIGHT PART OF THE PRACTICE STRUCTURE? Common Factors Practice Principles “Practice” (Policy) Framework

8 Specific Knowledge of Problems & Solutions
Neglect Adoption Sexual Abuse Trauma Phobia Running Away

9 Evidence Supported Programs and Evidence Supported Interventions
Multi-systemic Family Therapy (MST) Multi-Dimensional Treatment Foster Care-Adolescent (MTFC-A) and MTFC-Pre KEEP EVIDENCE SUPPORTED MANUALIZED INTERVENTIONS Trauma Focused CBT Alternative Family-CBT Coping Cat

10 What Makes an Evidence Based Program Work?
We Really Do Not Know There has been very little deconstruction Multi-Dimensional Treatment Foster Care is a LARGE Collection of Practice Elements Parent Daily Report Parent Management Training for Foster and Biological Family Behavioral Group Work CBT for children Mentoring of Youth

11 What Makes a Manualized Evidence Supported Intervention Work?
We Really Do Not Know There has been very little deconstruction Trauma Focused CBT is a somewhat SMALLER Collection of Practice Elements Psycho-education Stress-management Narrative therapy Exposure therapy Cognitive restructuring Parental treatment

12 Three D’s: Stages to Practice Change
PCIT, PMT-O, TIY, SafeCare, MST, Triple P development for 30 years Discovery of new knowledge Development of highly effective evidence based methods Dissemination waits for efficacy to be established 30 Years

13 How will I ever master all these ESI manuals ???

14 The Common Elements Approach
Emphasis on evidenced-based treatments Step 1: Development of treatment manuals Step 2: Information overload: Too many treatment manuals to learn and manuals change as new knowledge is gained Step 3:

15 The Common Elements Approach
Using elements that are found across several evidence-supported, effective manualized interventions “Clinicians ‘borrow’ strategies and techniques from known treatments, using their judgment and clinical theory to adapt the strategies to fit new contexts and problems” (Chorpita, Becker & Daleiden, 2007, ) An alternate to using treatment manuals to guide practice Actual treatment elements become unit of analysis rather than the treatment manual Treatment elements are selected to match particular client characteristics

16 Identifying the Practice Elements
Trained coders reviewed 322 randomized controlled trials for major mental health disorders for children and teens; Over $500 million invested in these research studies Studies conducted over a span of 40 years More than 30,000 youth cumulatively in the study samples Approach: What features characterize successful treatments? What strategies are common across effective interventions? (Chorpita & Daleiden, 2009)

17 Coding Process for 322 RCTs:
Frequencies of practice elements from winning treatment groups were then tallied to see what practice elements were most commonly found in effective interventions 41 practice elements identified that were found in at least 3 of the 232 winning treatment groups

18 Tools to Support the Common Elements Approach
Subscription-based resources: PracticeWise Practitioner Guides Modular Approach to Therapy for Children (MATCH) PracticeWise Evidence-Based Services Database (PWEBS) PracticeWise Clinical Dashboards

19 Common Elements Practitioner Guides
Summarize the common elements of evidence-based treatments for youth; Handouts guide clinician in performing the main steps of the technique Currently 29 Treatment elements, including: Response cost Modeling Social Skills Time out Engagement with caregiver Guide is searchable by: treatment, audience (child, caregiver, family), purpose, objectives

20 Goals of this practice element
Example of printable PDF describing practice element: Audience Goals of this practice element Steps for using this practice element

21 MATCH Example: Putting Together Practice Elements

22 Clinical Dashboards Microsoft Excel based monitoring tool
Tracks achievement of treatment goals or other progress measures on a weekly/session basis Documents which practice elements were used when Dashboard can be customized: Display up to 5 progress measures; Write-in additional practice elements Potential uses: Documenting session activities Tracking client progress Clinical supervision

23 Document which practice element was used when
Progress Measures Document which practice element was used when

24 Common Factors (CDOI) Effective therapy arises from allegiance to a treatment model, monitoring of change, and creating a strong therapeutic alliance Feedback from clients on their level of functioning Feedback to therapists on the therapeutic alliance A coherent treatment approach that encourages action to change Duncan et al., (2010) Heart and Soul of Change: Delivering What Works in Therapy (2nd Edition). Washington, DC: APA

25 Positive Implications for Therapy
“A continuous feedback or practice-based evidence approach individualizes psychotherapy based on treatment response and client preference; systematic feedback addresses the dropout problem, as well as treatment and therapist variability, and could increase consumer confidence in the outcome of therapeutic services” (p. 702). I liked this summarizing quote, but you may wish to exclude it. Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 25

26 Client-Directed, Outcome-Informed (CDOI) Treatment & Wrap Around
Adapt to specific individual and family needs based on client feedback Move from punitive and restrictive to optimistic and responsive interventions Utilize brief and systemic client-report measures throughout therapy Strengths-based and culturally responsive “At its core, wraparound is flexible, comprehensive, and team-based.” (p. 65) Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community collaboration. Journal of Systemic Therapies, 28, (3), 26

27 Tools for Feedback: ORS and SRS
Reliable and valid four-item, self-report instruments used at each meeting Scored and interpreted in a collaborative effort between client and therapist Rather than the therapist assigning meaning to a client’s feedback, the client explains the meaning behind the mark on the scale Help identify alliance strengths and weaknesses in therapy Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community collaboration. Journal of Systemic Therapies, 28, (3), 27

28 Formatted for Children… the CORS and CSRS
Similar scales designed for use with children ages 6-12 Written at a third grade reading level Used to track effectiveness and therapeutic alliance as reported by children and their parents or caretakers. CORS shows strong reliability (alpha=.84) and validity as compared to a longer youth outcome questionnaire (Pearson’s coefficient=.61) Gives youth a voice in their own therapy Duncan, B. L., Sparks, J. A., Miller, S. D., Bohanske, R. T. & Claud, D. A. (2006) Giving youth a voice: A preliminary study of the reliability and validity of a brief outcome Measure for children, adolescents, and caretakers. Journal of Brief Therapy, 5, (2), 28

29 Outcome Rating Scale (ORS): Adults
Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing. Individually (Personal well-being) I I Interpersonally (Family, close relationships) I I Socially (Work, school, friendships) Overall (General sense of well-being) Institute for the Study of Therapeutic Change © 2000, Scott D. Miller & Barry L. Duncan 29

30 Child Outcome Rating Scale (CORS)
How are you doing? How are things going in your life? Please make a mark on the scale to let us know. The closer to the smiley face, the better things are. The closer to the frowny face, things are not so good. If you are a caretaker filling out this form, please fill out according to how you think the child is doing. Me (How am I doing?) I I Family (How are things in my family?) I I School (How am I doing at school?) Everything (How is everything going?) Institute for the Study of Therapeutic Change © 2003, Barry L. Duncan, Scott D. Miller & Jacqueline A. Sparks 30

31 Session Rating Scale (SRS V.3.0): Adults
Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience. Relationship I did not feel heard, I felt heard, understood, and I I understood, and respected. Goals and Topics We did not work on We worked on and or talk about what I talked about what I wanted to work on I I wanted to work on or talk about and talk about. Approach or Method The therapist’s The therapist’s approach is not a I I approach is a good fit for me good fit for me. Overall Overall, today’s There was something session was right for I I missing in the session today. me. Institute for the Study of Therapeutic Change © 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

32 Child Session Rating Scale (SRS V.3.0)
How was our time together today? Please put a mark on the lines below to let us know if how you feel. Listening Did not always listen to me I I Listened to me. How Important What we did and talked What we did and about was not talked about really that I I were important important to me to me. What We Did I did not like I liked what we What we did I I did today. today. Overall I wish we could I hope we do the do something I I same kind of different things next time. Institute for the Study of Therapeutic Change © 2003, Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, and Lynn D. Johnson

33 Implementing CDOI Services in Wrap Around Services
Using a formal feedback form such as the ORS/CORS and SRS/CSRS can unite the treatment discourse with the client-directed wraparound ideology Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community collaboration. Journal of Systemic Therapies, 28, (3), 33

34 Measurement Feedback Systems
A MFS is a battery of comprehensive measures administered frequently concurrent with treatment, providing timely feedback to clinicians and supervisors to report on clinical processes and treatment adherence (Bickman, 2008). A good MFS should have measures that are: short, Psychometrically sound, and useful in everyday practice by clinicians MFSs should assess several domains by multiple reporters that include treatment progress (e.g. youth and family outcomes) and treatment processes (e.g. therapeutic alliance and treatment activities). A MFS provides systematic feedback that can be used to enhance clinical decision-making, improve accountability, drive program planning, and inform treatment effectiveness (Chorpita et al. 2008; Kelley & Bickman 2009).

35 First CDOI/MFS RCT Couples using the feedback measure, ORS, (N=103) at pre- and posttreatment and follow-up, compared to couples receiving treatment as usual (TAU) (N=102): Achieved almost 4 times the rate of clinically significant change Maintained a significant advantage on the ORS at 6-month follow-up Showed greater marital satisfaction and lower rates of separation or divorce The feedback condition showed a moderate to large effect size (0.50) The SRS was used by therapists as well but not included in the analysis. Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 35

36 Client Feedback as a Common Factor (or Element)?
This study provides reliable support for alliance building and monitoring treatment progress for clients and therapists in couple therapy. Feedback tools (e.g., ORS and SRS) that are not linked with a certain therapy or method can be used in community settings more easily than specific treatment packages. Further research may show the extent to which the increased therapeutic engagement or allegiance effects can influence the positive effect of the feedback tools. Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 36


38 Predicted Probability Of Negative Exits By Prior Placements And Intervention Group

39 MTFC-P and KEEP Implications
The Case: School of Social Work Opportunities We can change biological characteristics of children—including stress hormones and executive functioning—with consistent responsive social interventions The use of the Parent Daily (or Weekly) Report and Support Groups may be common elements of benefit. Perhaps could also be used more in parent training (a la PMTO) and post-adoption services

40 Project KEEP: (MTFC-Lite)
Foster Parent Groups Good behavioral group work a la Sheldon Rose Appreciate the foster parents efforts Reward their successes Demonstrate and role play skills Pre-teaching (shaping the antecedents) Parent Daily Report (PDR) Which of these problems occurred in the last 24 hours? How stressful did you find it?

41 “Practice” (Policy) Framework
Specific Knowledge of Problem & Solutions Evidence Supported Programs Common (Practice) Elements Common Factors “Practice” (Policy) Framework

42 Building on Evidence Supported Interventions for Children and Families
Adoption Competence (EXAMPLE) Understand adoption triad issues to Increase the acceptability of services by adopting parents & children Evidence Supported Programs Multi-systemic Therapy (MST) Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A) Evidence Supported Manualized Interventions Scott Hengeller’s Multi Systemic Therapy (MST) Cohen and Mannarino’s Trauma Focused-CBT Common Elements Approach Chorpita and colleagues Common Factors Approach Duncan, Lambert and Sparks (CDOI) Practice (Policy) Framework Commitment to “Place Matters” or “Family Focused Services” or “Safety, Permanency & Well-Being”

43 Practice Principles Example, Doug Kirby Pregnancy and STI Practice Principles Hurlburt and Barth on parenting programs MORE ART THAN SCIENCE Most of these practices have not been studied in isolation and we cannot tell what their overlap might be—some may be inert.

44 Parent Training Programs

45 Basic Components of Effective Parent Training
Social learning framework Strengthening parent-child relationship Effectively use praise and reward Sets clear and effective limits Reserves most significant consequences for targeted, limited behaviors Strictly limits negative consequences Parent Training + may have worse outcomes than parent training alone (CDC) Addresses family as well as parent-child issues Hurlburt, M., Barth, R.P., Leslie, L. & Landsverk, J. (in press). Haskins, R., Wulczyn, F., & Webb, M. (Eds).  Research on child protection: Findings from NSCAW. Washington, DC: Brookings.

46 Delivering Effective Parent Training Programs
Detailed materials corresponding to specific, narrowly focused parenting skills Specific means of monitoring changes in parenting practices (e.g., homework) Parents take active, participatory role in learning and practicing skills Minimum 15 hours of intervention and 25 hours for group format Rigor of supervision processes to ensure program delivery with fidelity

47 Thank you for this opportunity
Comments? OR ‘S

48 Partial References I Aarons, G. A. (2005). Measuring provider attitudes toward evidence-based practice: Consideration of organizational context and individual differences. Child and Adolescent Psychiatric Clinics of North America, 14(2), Barth, R. P. (2005). Foster care is more cost-effective than shelter care: Serious questions continue to be raised about the utility of group care use in child welfare services. Child Abuse & Neglect, 29, Barth, R. P., Greeson, J. K. P., Guo, S., Green, R. L., Hurley, S., & Sisson, J. (2007). Outcomes for youth receiving intensive in-home therapy or residential care: A comparison using propensity scores. American Journal of Orthopsychiatry, 77(4), Barth, R. P., Landsverk, J., Chamberlain, P., Reid, J., Rolls, J., Hurlburt, M., et al. (2006). Parent training in child welfare services: Planning for a more evidence based approach to serving biological parents. Research on Social Work Practice. Bruns, E. J., Hoagwood, K. E., Rivard, J. C., Wotring, J., Marsenich, L., & Carter, B. (2008). State implementation of evidence-based practice for youths, part II: Recommendations for research and policy. Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), Chamberlain, P., Price, J. M., Reid, J. B., Landsverk, J., Fisher, P. A., & Stoolmiller, M. (2006). Who disrupts from placement in foster and kinship care? Child Abuse & Neglect, 30(4), Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological, interventions: Controversies and evidence. Annual Review of Psychology, 52, Chorpita, B. F., & Daleiden, E. L. (2009). Mapping Evidence-Based Treatments for Children and Adolescents: Application of the Distillation and Matching Model to 615 Treatments From 322 Randomized Trials. Journal of Consulting and Clinical Psychology, 77(3), Dawson, K., & Berry, M. (2002). Engaging families in child welfare services: An evidence-based approach to best practice. Child Welfare, 81,

49 Partial References II Doyle, J. J. (2007). Child protection and child outcomes: Measuring the effects of foster care. American Economic Review, 97(5), Flynn, L. M. (2005). Family perspectives on evidence-based practice. Child and Adolescent Psychiatric Clinics of North America, 14(2), Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology, 37(1), Lambert, M. J. (2005). Emerging methods for providing clinicians with timely feedback on treatment effectiveness: An introduction. Journal of Clinical Psychology, 61(2), Lee, B. R., & Thompson, R. (2008). Comparing outcomes for youth in treatment foster care and family-style group care. Children and Youth Services Review, 30(7), McCrae, J. S., Barth, R.P., & Guo, S. (in press). Changes in emotional-behavioral problems following usual care mental health services for maltreated children: A propensity score analysis. American Journal of Orthopsychiatry. McKay, M., Hibbert, R, Hoagwood, K, Rodriguez, J, Murray, L, Legerski, J, & Fernandez, D. (2004). Integrating evidence-based engagement interventions into “real world” child mental health settings. Brief Treatment and Crisis Intervention 4,2, Messer, S.B. & Wampold, B.D. (2006). Let’s face facts: Common factors are more potent than specific treatment ingredients. Clinical Psychology: Science & Practice, 9, Miranda, J., Bernal, G., Laua, A., Hwang, W. C., & LaFramboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1,

50 Partial References III
Palinkas, L. A., Aarons, G. A., Chorpita, B. F., Hoagwood, K., Landsverk, J., & Weisz, J. R. (2009). Cultural Exchange and the Implementation of Evidence-Based Practices Two Case Studies. Research on Social Work Practice, 19(5), Pine, B. A., Spath, R., Werrbach, G. B., Jenson, C. E., & Kerman, B. (2009). A better path to permanency for children in out-of-home care. Children and Youth Services Review, 31(10), Price, J. M., Chamberlain, P., Landsverk, J., & Reid, J. (2009). KEEP foster-parent training intervention: model description and effectiveness. Child & Family Social Work, 14(2), Ryan, J. P., Marshall, J. M., Herz, D., & Hernandez, P. A. (2008). Juvenile delinquency in child welfare: Investigating group home effects. Children and Youth Services Review, 30(9), Saunders, B. E., Berliner, L., & Hanson, R. F. E. (2003). Child physical and sexual abuse: Guidelines for treatment (Final report: January 15, 2003). Charleston, SC: National Crime Victims Research and Treatment Center. Sundell, K., and Vinnerljung, B. (2004). Outcomes of family group conferencing in Sweden: A 3-year follow-up. Child Abuse & Neglect, 28, Taussig, H. N., Clyman, R. B., & Landsverk, J. (2001). Children who return home from foster care: A 6-year prospective study of behavioral health outcomes in adolescence. Pediatrics, 108,

51 Partial References IV Thomlison, B. (2003). Characteristics of evidence-based child maltreatment interventions. Child Welfare, 82, Wang, P. S., Ulbricht, C. M., & Schoenbaum, M. (2009). Improving Mental Health Treatments Through Comparative Effectiveness Research. Health Affairs, 28(3), Weisz, J. R., Jensen-Doss, A., & Hawley, K. M. (2006). Evidence-based youth psychotherapies versus usual clinical care - A meta-analysis of direct comparisons. American Psychologist, 61(7), Wilensky, G. R. (2006). Developing a center for comparative effectiveness information. Health Affairs, 25(6), W572-W585 Wilson, S. J., Lipsey, M. W., & Soydan, H. (2003). Are mainstream programs for juvemajority youth? A meta-analysis of outcomes research. Research on Social Work Practice, 13(1), 3-26nile delinquency less effective with minority youth than Wulczyn, F., Barth, R. P., Yuan, Y. Y., Jones Harden, B., & Landsverk, J. (2008). Evidence for child welfare policy reform. New York: Transaction De Gruyter.

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