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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 [email protected] umaryland. edu
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
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.
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
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
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”
N HE O T ? G OF RE Not Drawn to Scale Specific IN T U U Regarding Importance Knowledge of C AR CT Problem & Solutions FO T P TRU E H S W IG E E R TIC Evidence Supported A H C T RA Programs P (Manualized Interventions) Common (Practice) Elements Common Factors Practice Principles “Practice” (Policy) Framework 7
Specific Knowledge of Problems & Solutions • • • Neglect Adoption Sexual Abuse Trauma Phobia Running Away
Evidence Supported Programs and Evidence Supported Interventions PROGRAMS • 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
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
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
Three D’s: Stages to Practice Change PCIT, • Discovery of new knowledge PMT-O, TIY, • Development of highly effective evidence based methods 30 Years • Dissemination waits for efficacy to be established Safe. Care, MST, Triple P development for 30 years
How will I ever master all these ESI manuals ? ? ?
The Common Elements Approach Step 1: Emphasis on evidenced-based treatments Step 2: Development of treatment manuals Step 3: Information overload: Too many treatment manuals to learn and manuals change as new knowledge is gained
The Common Elements Approach • Using elements that are found across several evidencesupported, 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, 648 -649) – 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
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)
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
Tools to Support the Common Elements Approach • www. practicewise. com • Subscription-based resources: – Practice. Wise Practitioner Guides – Modular Approach to Therapy for Children (MATCH) – Practice. Wise Evidence-Based Services Database (PWEBS) – Practice. Wise Clinical Dashboards
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
Example of printable PDF describing practice element: Audience Goals of this practice element Steps for using this practi ce eleme nt
MATCH Example: Putting Together Practice Elements Start
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
gress Pro s asure Me Docume nt which practice element was used when
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 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 (2 nd Edition). 24
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). 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), 693 -704.
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), 63 -76.
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 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), 63 -76.
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), 71 -88.
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) I -------------------------------------------------- I Overall (General sense of well-being) I -------------------------------------------------- I Institute for the Study of Therapeutic Change www. talkingcure. com © 2000, Scott D. Miller & Barry L. Duncan
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? ) I -------------------------------------------------- I Everything (How is everything going? ) I -------------------------------------------------- I Institute for the Study of Therapeutic Change www. talkingcure. com © 2003, Barry L. Duncan, Scott D. Miller & Jacqueline A. Sparks
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. I did not feel heard, understood, and Relationship I ---------------------------------------- I I felt heard, understood, and respected. Goals and Topics We did not work on We worked on and or talk about what I wanted to work on and talk about. I --------------------------------------------- I talked about what I wanted to work on or talk about Approach or Method The therapist’s approach is not a good fit for me. I ---------------------------------------------- I The therapist’s approach is a good fit for me Overall, today’s session was right for I --------------------------------------------- I me. Institute for the Study of Therapeutic Change www. talkingcure. com © 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson There was something missing in the session today.
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 really that important to me. I -------------------------------------- I talked about were important to me. What We Did I did not like What we did today. I -------------------------------------- I I liked what we did today. Overall I wish we could do something different. I -------------------------------------- I • I hope we do the same kind of things next time. Institute for the Study of Therapeutic Change www. talkingcure. com © 2003, Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, and Lynn D. Johnson
Implementing CDOI Services in Wrap Around Services ü 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), 63 -76.
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).
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) 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 , 693 -704.
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 , 693 -704.
Predicted Probability Of Negative Exits By Prior Placements And Intervention Group KEEP
MTFC-PSchool of Social Work Opportunities The Case: and KEEP Implications • 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
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?
Specific Knowledge of Problem & Solutions Evidence Supported Programs Common (Practice) Elements Common Factors “Practice” (Policy) Framework 41
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”
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.
Parent Training Programs SO FAR …. . NO PARENT TRAINING PROGRAMS HAVE THE HIGHEST SCIENTIFIC RATING AND THE HIGHEST CHILD WELFARE RELEVANCE RATINGS Source: http: //www. cebc 4 cw. org/search/topical-area/1, retrieved, May 13, 2010
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.
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
Thank you for this opportunity en t s? Co m m OR ‘S
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