A Common Elements Approach to Children's Services

Presented to the

The Use of Evidence in Child Welfare Practice and PolicyAn International Perspective on Future Directions

Haruv Institute, Bar-Ilan University, IsraelMay 26, 2010

Richard P. BarthATLANTIC COAST CHILD WELFARE IMPLEMENTATION CENTER

School of Social WorkUniversity of MarylandBaltimore, MD 21201rbarth@ssw.umaryland.edu

Summary

• Evidence based practices need to be based, primarily, on practice principles and common pracice 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

A Language for Evidence Supported Interventions for Children and Families

• Specific Competence – Needed to increase the acceptability of services and, possibly, to

improve interventions• Evidence Supported Programs

– Multi-systemic Therapy (MST); – “Wrap Around”– Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A)

• Evidence Supported Manualized Interventions – e.g., Cohen and Mannarino’s Trauma Focused-CBT

• Common (Practice) Elements Approach – Chorpita and colleagues

• Common Factors Approach and Measurment Feedback Systems (MFS)– Duncan, Lambert and Sparks (CDOI)

• Practice Principles– Hurlburt & Barth Parent Training Programs

• Practice (Policy) Framework– Commitment to “Place Matters” or “Family Focused Services” or “Safety

First”, or Safety, Permanency & Well-Being”

Specific Knowledge of

Problem & Solutions

Evidence Supported Programs

(Manualized Interventions)

Common (Practice) Elements

6“Practice” (Policy) Framework

Common Factors

Not Drawn to Scale Regarding the Number

in Each Set

ARE WE F

OCUING O

N

THE RIG

HT PART O

F THE

PRACTICE S

TRUCTURE?

Practice Principles

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?

• Trauma Focused CBT is more tightly manualized with a somewhat SMALLER Collection of Practice Elements– Psycho-education– Stress-management– Narrative therapy– Exposure therapy– Cognitive restructuring– Parental treatment

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 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, 648-649)

• 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:

–PracticeWise Practitioner Guides–Modular Approach to Therapy for

Children (MATCH)–PracticeWise Evidence-Based Services

Database (PWEBS)–PracticeWise 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

practice

element

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

Progress

Measures

Document which practice element was used when

Common Factors (Client Directed Outcome Informed)

• 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

22Duncan et al., (2010) Heart and Soul of Change: Delivering What Works in Therapy (2nd Edition). Washington, DC: APA

Practice Based Evidence

“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…” (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, 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 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), 63-76.

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 Changewww.talkingcure.com

© 2000, Scott D. Miller & Barry L. Duncan

Outcome Rating Scale (ORS): AdultsLooking 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.

RelationshipI did not feel heard,

I felt heard,understood, and I -------------------------------------------------------------------------------- I understood, and respected.

Goals and TopicsWe 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 MethodThe therapist’s The therapist’s

approach is not a I ------------------------------------------------------------------------------------------- I approach is a good fit for me

good fit for me.

OverallOverall, today’s There was something

session was right for I ------------------------------------------------------------------------------------------ I missing in the session today.

me.

Institute for the Study of Therapeutic Change

www.talkingcure.com

© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

Session Rating Scale (SRS V.3.0): AdultsPlease rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

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.

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 Changewww.talkingcure.com

© 2003, Barry L. Duncan, Scott D. Miller & Jacqueline A. Sparks

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.

ListeningDid not always

listen to me I ---------------------------------------------------------------------------- I Listened to me.

How ImportantWhat 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 DidI did not like I liked what we

What we did I --------------------------------------------------------------------------- I did today.

today.

OverallI 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

www.talkingcure.com• © 2003, Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, and Lynn D. Johnson

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.

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).

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.

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.

Other Common Elements/MFS: The Parent Daily Report

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?

Predicted Probability Of Negative Exits By Prior Placements And Intervention Group

KEEP

MTFC 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

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.

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

Practice Policy Framework

• Lack of clarity about the purposes of societal efforts to protect children, promote their well-being, and support families will undermine the commitment to advance new treatment approaches and handicap efforts to generate measurement feedback systems at the policy level—a crucial flaw.

Thank you for this opportunity

Comments

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