Presentation on theme: "A Common Elements Approach to Children's Services"— Presentation transcript:
1 A Common Elements Approach to Children's Services Presented to theThe Use of Evidence in Child Welfare Practice and PolicyAn International Perspective on Future DirectionsHaruv Institute, Jerusalem, IsraelMay 26, 2010Richard P. BarthATLANTIC COAST CHILD WELFARE IMPLEMENTATION CENTERSchool of Social WorkUniversity of MarylandBaltimore, MD 21201Cycles—from the practical and specific to the general and conceptualNearly 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 levelA study about every aspect of CW in generalFor me, it’s time to cycle back and get specific; CAIRN has offered that.This training opportunity, too.Analyzing outcomes-SDM-AB 636
2 SummaryEvidence based practices need to be based, primarily, on practice principles and common practice elements, not on manualsIncreasing the uptake of evidence based methods will best be achieved by increasing knowledge of common practice elements and common factorsAdapting evidence based practices to international contexts will require emphasis on common factors
3 The Alphabet of EBPWhat 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 ProgramsMulti-dimensionalEvidence Supported InterventionsCommon (Practice) ElementsCommon Factors (CD OI)Client directedOutcome informedCoherent treatment strategyPractice PrinciplesPractice (Policy) Framework
5 EBP and ESIs and Practice Guidelines Evidence Based PracticeProcedures and processes that result in the integration of the best research evidence with clinical expertise and client valuesEvidence Supported InterventionsInterventions that have the support of the “best research evidence” showing their efficacy or effectivenessPractice Guidelines or PrinciplesA 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 interventionsEvidence 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-CBTCommon (Practice) Elements Approach (28 Practice Elements)Chorpita and colleaguesCommon Factors Approach (3 Common Factors)Duncan, Lambert and Sparks (CDOI)Practice PrinciplesParent Training Dimensions (UK work or Hurlburt & Barth)Practice (Policy) FrameworkCommitment to “Place Matters” or “Family Focused Services” or “Safety, Permanency & Well-Being”
7 “Practice” (Policy) Framework SpecificKnowledge ofProblem & SolutionsEvidence Supported Programs(Manu alized Interv ention s)Common (Practice) ElementsNot Drawn to Scale Regarding ImportanceARE WE FOCUING ON THE RIGHT PART OF THE PRACTICE STRUCTURE?Common FactorsPractice Principles“Practice” (Policy) Framework
8 Specific Knowledge of Problems & Solutions NeglectAdoptionSexual AbuseTraumaPhobiaRunning Away
9 Evidence Supported Programs and Evidence Supported Interventions Multi-systemic Family Therapy (MST)Multi-Dimensional Treatment Foster Care-Adolescent (MTFC-A) and MTFC-PreKEEPEVIDENCE SUPPORTED MANUALIZED INTERVENTIONSTrauma Focused CBTAlternative Family-CBTCoping Cat
10 What Makes an Evidence Based Program Work? We Really Do Not KnowThere has been very little deconstructionMulti-Dimensional Treatment Foster Care is a LARGE Collection of Practice ElementsParent Daily ReportParent Management Training for Foster and Biological FamilyBehavioral Group WorkCBT for childrenMentoring of Youth
11 What Makes a Manualized Evidence Supported Intervention Work? We Really Do Not KnowThere has been very little deconstructionTrauma Focused CBT is a somewhat SMALLER Collection of Practice ElementsPsycho-educationStress-managementNarrative therapyExposure therapyCognitive restructuringParental treatment
12 Three D’s: Stages to Practice Change PCIT,PMT-O,TIY,SafeCare,MST,Triple Pdevelopment for 30 yearsDiscovery of new knowledgeDevelopment of highly effective evidence based methodsDissemination waits for efficacy to be established30 Years
13 How will I ever master all these ESI manuals ???
14 The Common Elements Approach Emphasis on evidenced-based treatmentsStep 1:Development of treatment manualsStep 2:Information overload: Too many treatment manuals to learn and manuals change as new knowledge is gainedStep 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 practiceActual treatment elements become unit of analysis rather than the treatment manualTreatment 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 studiesStudies conducted over a span of 40 yearsMore than 30,000 youth cumulatively in the study samplesApproach: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 interventions41 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 GuidesModular 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 techniqueCurrently 29 Treatment elements, including:Response costModelingSocial SkillsTime outEngagement with caregiverGuide is searchable by: treatment, audience (child, caregiver, family), purpose, objectives
20 Goals of this practice element Example of printable PDF describing practice element:AudienceGoals of this practice elementSteps for using this practice element
21 MATCH Example: Putting Together Practice Elements Start
22 Clinical Dashboards Microsoft Excel based monitoring tool Tracks achievement of treatment goals or other progress measures on a weekly/session basisDocuments which practice elements were used whenDashboard can be customized:Display up to 5 progress measures;Write-in additional practice elementsPotential uses:Documenting session activitiesTracking client progressClinical supervision
23 Document which practice element was used when Progress MeasuresDocument 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 allianceFeedback from clients on their level of functioningFeedback to therapists on the therapeutic allianceA coherent treatment approach that encourages action to changeDuncan 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 feedbackMove from punitive and restrictive to optimistic and responsive interventionsUtilize brief and systemic client-report measures throughout therapyStrengths-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 meetingScored and interpreted in a collaborative effort between client and therapistRather than the therapist assigning meaning to a client’s feedback, the client explains the meaning behind the mark on the scaleHelp identify alliance strengths and weaknesses in therapySparks, 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 6-12Written at a third grade reading levelUsed 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 therapyDuncan, 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
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 ideologySparks, 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, anduseful in everyday practice by cliniciansMFSs 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 RCTCouples 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 changeMaintained a significant advantage on the ORS at 6-month follow-upShowed greater marital satisfaction and lower rates of separation or divorceThe 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 KEEP
39 MTFC-P and KEEP Implications The Case: School of Social Work OpportunitiesWe can change biological characteristics of children—including stress hormones and executive functioning—with consistent responsive social interventionsThe 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 GroupsGood behavioral group work a la Sheldon RoseAppreciate the foster parents effortsReward their successesDemonstrate and role play skillsPre-teaching (shaping the antecedents)Parent Daily Report (PDR)Which of these problems occurred in the last 24 hours?How stressful did you find it?
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 & childrenEvidence Supported ProgramsMulti-systemic Therapy (MST)Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A)Evidence Supported Manualized InterventionsScott Hengeller’s Multi Systemic Therapy (MST)Cohen and Mannarino’s Trauma Focused-CBTCommon Elements ApproachChorpita and colleaguesCommon Factors ApproachDuncan, Lambert and Sparks (CDOI)Practice (Policy) FrameworkCommitment to “Place Matters” or “Family Focused Services” or “Safety, Permanency & Well-Being”
43 Practice PrinciplesExample, Doug Kirby Pregnancy and STI Practice PrinciplesHurlburt and Barth on parenting programsMORE ART THAN SCIENCEMost 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 SO FAR …..NO PARENT TRAINING PROGRAMS HAVE THE HIGHEST SCIENTIFIC RATING AND THE HIGHEST CHILD WELFARE RELEVANCE RATINGSSource: retrieved, May 13, 2010
45 Basic Components of Effective Parent Training Social learning frameworkStrengthening parent-child relationshipEffectively use praise and rewardSets clear and effective limitsReserves most significant consequences for targeted, limited behaviorsStrictly limits negative consequencesParent Training + may have worse outcomes than parent training alone (CDC)Addresses family as well as parent-child issuesHurlburt, 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 skillsSpecific means of monitoring changes in parenting practices (e.g., homework)Parents take active, participatory role in learning and practicing skillsMinimum 15 hours of intervention and 25 hours for group formatRigor of supervision processes to ensure program delivery with fidelity
48 Partial References IAarons, 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 IIDoyle, 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 IVThomlison, 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-W585Wilson, 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 thanWulczyn, F., Barth, R. P., Yuan, Y. Y., Jones Harden, B., & Landsverk, J. (2008). Evidence for child welfare policy reform. New York: Transaction De Gruyter.