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MHS6069 Child and Adolescent Behavioral Health Cathy Sowell, LCSW

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Evidence-based practice in context

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Summary

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Benefits and Concerns of Common Practice Approach

Index

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1.

Overview

2.

Model of Evidence Based Research

3.

Specificity of Disorders

4.

Efficacy Research

5.

Criticisim of EBPs

6.

Delays in Treatment

7.

Fidelity of Practice

8.

Assessment of Contexts

9.

Facilitative Inhibitating Factors

10.

Attitudes of Providers

11.

Complex Needs

12.

Characteristics of Usual Practice

13.

Organizational Factors

14.

Resource Availability

15.

Common Pratice Elements

  • Explore evidence-based practice and its application across the behavioral health care continuum.
  • Review factors aiding and hindering effective use, along with evidence-based interventions for children and adolescents.

Overview

Definition: Evidence-Based Interventions

The goal of the movement was that “clinical decisions would be supported by accurate, timely, and up-to-date clinical information, reflecting the best available evidence”.

Evidence-based interventions are couched within a broader evidence-based practice movement.

The Institute of Medicine defines evidence-based practice as the integration of best research evidence with clinical expertise and patient values, characteristics, culture, and preferences to achieve optimum care.

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Model of Evidence-Based Research

  • Research shows effectiveness of interventions for psychosocial concerns in children/adolescents.
  • Evidence-based literature focuses on treating well-defined disorders.
  • Youth psychosocial problems often categorized as externalizing/internalizing, substance use, suicidality, traumatic stress.

Specificity of Disorders

  • Some interventions, like CBT and Psychodynamic Therapy, show efficacy across multiple disorders.
  • Multisystemic Therapy is effective for substance use and behavioral challenges.
  • DBT is promising for addressing trauma-related issues like suicidality, substance use, and mood disorders.

Efficacy Research

  • Increased use of Evidence-Based Practices (EBPs) in children's services agencies.
  • Criticisms from providers, resistance from researchers and policymakers.

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Practitioner Perspective of EBPs

Criticism of EBPs

  • Research explores adaptation of intervention models by practitioners in practice settings.
  • Modifications made due to varying characteristics, needs of clients, and contextual differences.

Implementation Science

  • Recent emphasis on high-fidelity implementation for interventions.
  • The question arises: Can manualized treatments, implemented with high fidelity, achieve outcomes comparable to controlled clinical trials?
  • Research shows therapies can be successful in community settings, but process evaluation highlights challenges and costs.

Fidelity of Practice

  • Research involves assessing communities and service settings, and adjusting implementation to match context.
  • Approach extends beyond individual-provider interactions to interactions within and across service systems.
  • Programs for broad adoption require structured needs assessments, stakeholder partnerships, community engagement, and strategic planning for responsiveness and flexibility.

Assessment of Contexts

  • Factors influencing EBP implementation: provider attitudes, population characteristics, usual practice, organizational factors, resource availability.
  • Difficulty achieving fidelity to treatment model highlights need for integrative approach to implementation.
  • Integrative approach beneficial for applying evidence in practice amidst various influencing factors.
  • The prefrontal cortex, responsible for behavioral control, is immature in adolescents, leading to limited ability to inhibit impulsive, pleasure-seeking behaviors and engage in logical reasoning.

Facilitative or Inhibiting Factors

  • Service providers' attitudes crucial to successful implementation of evidence-based interventions.
  • Efficacious treatments in research settings may not be perceived as practical in real-world settings.
  • Practitioner attitudes vary based on treatment nature, organizational context, clinician experiences/preferences; skepticism towards highly structured programs.

Attitudes of Providers

  • Practices often developed and tested with homogeneous populations, leading to perceived limited appropriateness for families with complex needs.
  • Decision-makers must understand circumstances for adapting interventions to match specific child/family needs.

Complex Needs

  • Characteristics of usual practice influence implementation success.
  • Service settings valuing provider freedom, autonomy, and eclecticism may resist manualized models.
  • Organizational cultures endorsing person-centered approaches may resist prescriptive practices.
  • A good fit between new treatment model and current practice can lead to successful adoption and implementation.

Characteristics of Usual Practice

The key organizational factors that have received the most attention are organizational culture, organizational climate, mission and philosophy of the organization, leadership, and network connectedness.

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Organizational Climate

Organizational Factors

  • Effective implementation requires extensive training and ongoing support for practitioners.
  • Sustaining implementation necessitates adequate funding, resources, incentives, staffing, administrative support, and organizational changes.

Resource Availablity

  • Problem-Solving Skills
  • Connection Between Thoughts, Feelings, and Behavior
  • Self or Parent Behavior Monitoring and Reward
  • Future Planning
  • Building a Working Alliance, Rapport or Relationship
  • Providing Psychoeducation
  • Cognitive Restructuring
  • Treatment Goal Discussion and Consensus

Common effective strategies, applicable across various conditions and intervention models, prioritize:

  • Strategy: Focus on effective practice elements across interventions rather than specific treatment models.
  • Emphasize core/common practice elements for flexibility and effectiveness.
  • Effective strategies applicable across various conditions, irrespective of intervention model.

Common Practice Elements

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Concerns About Common Practice Approach
Benefits of Common Practice Elements Approach

Common Practice Elements Approach

Whether we are utilizing an evidence-based strategy or specific evidence-based intervention approach, best practice involves the integration of the best available evidence with clinical expertise and individual community context and needs.

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A significantly looser application of the term would refer to “treatments supported by empirical evidence” or “interventions showing beneficial effects in outcome research.”

One of the most common models describes simply “discrete treatments for particular disorders that are supported by empirical evidence.”

Definition of Evidence-Based Interventions

Benefits of Common Practice Elements Approach

  • Common practice elements approach allows for varied use in evidence-based treatments across diverse concerns, stages, age groups, and cultural contexts.
  • Providers gain flexibility to identify effective strategies tailored to specific individuals, families, or groups based on successful treatment frequencies and matching variables.
  • Adaptability may alleviate barriers to EBP implementation, including provider attitudes and complex client characteristics.
  • Positive organizational climate linked to positive outcomes for children and families.
  • Fit between organizational mission and intervention goals is crucial.
  • Leadership associated with provider attitudes towards evidence-based treatment; commitment and preparedness important.

Organizational Climate

  • Critics argue EBP model is too narrow, and undervalues clinician expertise and client preferences.
  • Advocates for integrated approach: research, practical wisdom, individualized care.

Practitioner Perspective on EBPs

  • Limitation of practice elements approach: Breaking down treatment protocols may compromise effectiveness; doesn't address sequencing.
  • Specific strategies may not cover process factors like frequency, duration, assessment protocols, and provider training.
  • Importance of integrating therapeutic content, techniques, and effective program characteristics for a comprehensive approach.

Concerns About Common Practice Approach